=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487296547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 509 CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2019
-----------------------------------------------------
Last Update Date | 10/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1211 N 20TH AVE
-----------------------------------------------------
City | PASCO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99301-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-547-1759
-----------------------------------------------------
Fax | 509-547-1759
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1211 N 20TH AVE
-----------------------------------------------------
City | PASCO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99301-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-547-1759
-----------------------------------------------------
Fax | 509-547-1759
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF CHIROPRACTIC
-----------------------------------------------------
Name | JONATHON HESLOP
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 509-346-5822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------