=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699892299
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1ST CHOICE MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 10/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2441 STATE ST STE 10
-----------------------------------------------------
City | NEW ALBANY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47150-4962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-945-4500
-----------------------------------------------------
Fax | 812-945-4808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1241
-----------------------------------------------------
City | NEW ALBANY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47151-1241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-945-4500
-----------------------------------------------------
Fax | 812-945-4808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LANE CHRISTOPHER NUNIER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 812-945-4500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204C00000X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
-----------------------------------------------------
License Number | 01046210A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 05005346A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 08001189A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 08002214A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------