=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407091564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VONGUNTEN CHIROPRACTIC AND WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2008
-----------------------------------------------------
Last Update Date | 12/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4830 RIDGESIDE CIR SE
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44707-1133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-284-3646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4830 RIDGESIDE CIR SE
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44707-1133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-284-3646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ERIC VONGUNTEN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 330-284-3646
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC3695
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------