=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437504354
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARST CLINIC PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2016
-----------------------------------------------------
Last Update Date | 09/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3609 BRANDON AVE SW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24018-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-297-3440
-----------------------------------------------------
Fax | 540-297-9313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3609 BRANDON AVE SW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24018-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-297-3440
-----------------------------------------------------
Fax | 540-297-9313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GARY B GARST
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 540-297-3440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NX0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Chiropractor
-----------------------------------------------------
License Number | 0104000405
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------