=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750406302
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMITH MOUNTAIN LAKE CHIROPRACTIC CENTER P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2007
-----------------------------------------------------
Last Update Date | 12/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15388 MONETA RD
-----------------------------------------------------
City | MONETA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24121-5876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-297-1085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15388 MONETA RD
-----------------------------------------------------
City | MONETA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24121-5876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-297-1085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR PRESIDENT
-----------------------------------------------------
Name | DR. JAMES ANDREW SCHAIBLE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 540-297-1085
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 0104000790
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------