=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508877978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALSEMANN CHIROPRACTIC LIFE CENTER, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 04/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 MRYTLE ST
-----------------------------------------------------
City | CLAREMONT
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03743-2547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-542-7726
-----------------------------------------------------
Fax | 603-542-0471
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 MRYTLE ST
-----------------------------------------------------
City | CLAREMONT
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03743-2547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-542-7726
-----------------------------------------------------
Fax | 603-542-0471
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GARY L WALSEMANN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 603-542-7726
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 728-0704
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------