=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568856334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHORMATION CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2015
-----------------------------------------------------
Last Update Date | 03/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36304 KENAI SPUR HWY
-----------------------------------------------------
City | SOLDOTNA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99669-7105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-252-3156
-----------------------------------------------------
Fax | 907-262-9212
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36304 KENAI SPUR HWY
-----------------------------------------------------
City | SOLDOTNA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99669-7105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-252-3156
-----------------------------------------------------
Fax | 907-262-9212
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR AND OWNER
-----------------------------------------------------
Name | MISS CHERA HEATH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 907-262-9222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 430
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------