=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700127750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPITAL PAIN MANAGEMENT & REHAB CENTERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2013
-----------------------------------------------------
Last Update Date | 03/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10111 COLESVILLE RD SUITE 116A
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20901-2427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-328-0870
-----------------------------------------------------
Fax | 301-328-0714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10111 COLESVILLE RD SUITE 116A
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20901-2427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-328-0870
-----------------------------------------------------
Fax | 301-328-0714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. COREY BRYANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-328-0870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | S03629
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------