=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568458057
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN MARK SHARP D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 173 JONESTOWN RD
-----------------------------------------------------
City | WINSTON-SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27104-4616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-768-7227
-----------------------------------------------------
Fax | 336-768-3802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 173 JONESTOWN RD
-----------------------------------------------------
City | WINSTON-SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27104-4616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-768-7227
-----------------------------------------------------
Fax | 336-768-3802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1929
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 19279
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------