=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629000120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOBLES CHIROPRACTIC WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2006
-----------------------------------------------------
Last Update Date | 10/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15481 COMMERCIAL RD
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54138-9677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-276-3401
-----------------------------------------------------
Fax | 715-276-1533
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15481 COMMERCIAL RD
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54138-9677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-276-3401
-----------------------------------------------------
Fax | 715-276-1533
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JASON W. NOBLES
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 715-276-3401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3964-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------