=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508294281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARCIA CHIROPRACTIC WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2013
-----------------------------------------------------
Last Update Date | 10/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 GODDARD AVENUE
-----------------------------------------------------
City | IGNACIO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-563-1006
-----------------------------------------------------
Fax | 970-563-9591
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 224
-----------------------------------------------------
City | BAYFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81122-0224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-563-1006
-----------------------------------------------------
Fax | 970-563-9591
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. THOMAS PETER GARCIA
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 970-563-1006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4962
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------