=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427293547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWAY CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2008
-----------------------------------------------------
Last Update Date | 12/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3405 KENYON ST SUITE 206
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92110-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-224-5371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3405 KENYON ST SUITE 206
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92110-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-224-5371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR / CLINIC DIRECTOR
-----------------------------------------------------
Name | DR. BRIAN PAUL WHITE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 619-224-5371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC30075
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------