=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679924401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANT COUNTY CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2016
-----------------------------------------------------
Last Update Date | 09/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 S MAIN ST # 3
-----------------------------------------------------
City | DRY RIDGE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41035-7256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-375-3721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 236 REDWOOD DR
-----------------------------------------------------
City | DRY RIDGE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41035-7003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-375-3721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. GARY J MITCHELL
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 606-375-3721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5314
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------