=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447464698
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HUMPHREYS STREET CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 04/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 N HUMPHREYS ST
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-4531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-774-6601
-----------------------------------------------------
Fax | 928-774-2193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 N HUMPHREYS ST
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-4531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-774-6601
-----------------------------------------------------
Fax | 928-774-2193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRIMARY HEALTHCARE PROVIDER
-----------------------------------------------------
Name | MR. DANIEL W DAHL
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 928-774-6601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0762
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------