=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760636351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEVERSONS TAHQUITZ CANYON CHIROPRACTIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2008
-----------------------------------------------------
Last Update Date | 11/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2150 E TAHQUITZ CANYON WAY #5
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92262-7045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-325-4595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2150 E TAHQUITZ CANYON WAY #5
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92262-7045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-325-4595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. WILLIAM BRADLEY SEVERSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 760-325-4595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number | DC28533
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------