=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619607389
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASTERSON CHIROPRACTIC CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2022
-----------------------------------------------------
Last Update Date | 06/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 E MARKET ST
-----------------------------------------------------
City | WARSAW
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46580-3313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-549-3853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 6TH ST
-----------------------------------------------------
City | WINONA LAKE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46590-1110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-549-3853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SARAH LINDA MASTERSON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 574-549-3853
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------