=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699854901
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DC HEALTHCARE PROFESSIONAL LIMITED LIABILITY COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 01/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5559 N DAVIS HWY SUITE B
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-475-2675
-----------------------------------------------------
Fax | 850-475-2679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5559 N DAVIS HWY SUITE B
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-475-2675
-----------------------------------------------------
Fax | 850-475-2679
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR
-----------------------------------------------------
Name | DR. DONALD CLINTON CARLOCK JR.
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 850-475-2675
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH7173
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------