=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548565351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. RYAN HASENCLEVER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2011
-----------------------------------------------------
Last Update Date | 01/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 N 8TH ST 1
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72756-3738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-621-9006
-----------------------------------------------------
Fax | 479-621-9497
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 302 N 8TH ST 1
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72756-3738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-621-9006
-----------------------------------------------------
Fax | 479-621-9497
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. RYAN DALE HASENCLEVER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 479-621-9006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1705
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------