=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548459530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYNERGY CHIROPRACTIC CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2007
-----------------------------------------------------
Last Update Date | 04/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 WEST MEYER RD
-----------------------------------------------------
City | WENTZVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-639-9660
-----------------------------------------------------
Fax | 636-639-9135
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1420 WEST MEYER ROAD
-----------------------------------------------------
City | WENTZVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-639-9660
-----------------------------------------------------
Fax | 636-639-9135
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | RODNEY J BAMPTON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 636-639-9660
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2002020920
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------