=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649659525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NUSSLOCK CHIROPRACTIC CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2015
-----------------------------------------------------
Last Update Date | 05/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2332 HARRISON AVE STE C
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-3235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-502-2856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2332 HARRISON AVE STE C
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-3235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-502-2856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ANNA NUSSLOCK
-----------------------------------------------------
Credential | DC CCEP
-----------------------------------------------------
Telephone | 262-389-0105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 33263
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------