=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598879173
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOEHMER & KORTHUIS CHIROPRACTIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2006
-----------------------------------------------------
Last Update Date | 02/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12571 HESPERIA RD
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-5847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-241-2000
-----------------------------------------------------
Fax | 760-241-2100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12571 HESPERIA RD
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-5847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-241-2000
-----------------------------------------------------
Fax | 760-241-2100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JAMES DONALD BOEHMER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 760-241-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 19386
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------