=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437697513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI CHIROPRACTIC FAMILY & SPORTS MEDICINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2017
-----------------------------------------------------
Last Update Date | 03/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1175 LYONS RD BLDG E
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45458-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-404-2189
-----------------------------------------------------
Fax | 937-569-4989
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1175 LYONS RD BLDG E
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45458-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-404-2189
-----------------------------------------------------
Fax | 937-569-4989
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. DAVID MATTHEW HERMAN
-----------------------------------------------------
Credential | DC, CCSP, CCEP
-----------------------------------------------------
Telephone | 937-404-2189
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 4656
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------