=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720301088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORE CHIROPRACTIC CENTRE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2010
-----------------------------------------------------
Last Update Date | 03/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 NE RALPH POWELL RD SUITE C
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64064-2357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-272-6000
-----------------------------------------------------
Fax | 816-272-6001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3601 NE RALPH POWELL RD SUITE C
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64064-2357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-272-6000
-----------------------------------------------------
Fax | 816-272-6001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID ASHLEY BLACK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 816-272-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | MO2001002825
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------