=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730453085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POSITIVE EDGE CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2012
-----------------------------------------------------
Last Update Date | 03/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9988 HIBERT ST STE 205
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92131-2480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-635-9355
-----------------------------------------------------
Fax | 858-635-9104
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9988 HIBERT ST STE 205
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92131-2480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-635-9355
-----------------------------------------------------
Fax | 858-635-9104
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | NICCOLE MARIE ODELL
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 858-635-9355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 32118
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 32183
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------