=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649556630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC SPINE & JOINT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2011
-----------------------------------------------------
Last Update Date | 09/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 SE CENTURY DR STE D
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64081-3284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-655-2162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 SE CENTURY DR STE D
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64081-3284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-655-2162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NICOLE DIERKING
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 636-253-0761
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 2011000036
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------