=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689798092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAY J FITZGERALD DC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 04/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 1ST ST. SW
-----------------------------------------------------
City | WAGNER
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57380-0758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-384-5419
-----------------------------------------------------
Fax | 605-384-5410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 1ST ST. SW P.O. BOX 758
-----------------------------------------------------
City | WAGNER
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57380-0758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-384-5419
-----------------------------------------------------
Fax | 605-384-5410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAY JOSEPH FITZGERALD
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 605-384-5419
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 840
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------