=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780947945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FASKEN CHIROPRACTIC AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2012
-----------------------------------------------------
Last Update Date | 12/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 W ASH ST SUITE B
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-442-8959
-----------------------------------------------------
Fax | 573-443-8959
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 W ASH ST SUITE B
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-442-8959
-----------------------------------------------------
Fax | 573-443-8959
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. SHAYNA LOREN FASKEN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 573-442-8959
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------