=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619298395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREGORY CHIROPRACTIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2010
-----------------------------------------------------
Last Update Date | 01/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5604 I 55 S
-----------------------------------------------------
City | BYRAM
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39272-9402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-373-5767
-----------------------------------------------------
Fax | 601-372-4031
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5604 I 55 S
-----------------------------------------------------
City | BYRAM
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39272-9402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-373-5767
-----------------------------------------------------
Fax | 601-372-4031
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROGER MILTON GREGORY III
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 601-373-5767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 589
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------