=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639324874
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOPAC TRAIL CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2008
-----------------------------------------------------
Last Update Date | 12/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 N 48TH ST STE 1
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68504-3367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-465-0433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1184 W PIONEER PKWY
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76013-6367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MIKE CAPOBIANCO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-465-0433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------