=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790298461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ON THE GO CHIRO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2017
-----------------------------------------------------
Last Update Date | 11/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1606 S KIHEI RD
-----------------------------------------------------
City | KIHEI
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96753-8065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-463-9932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1606 S KIHEI RD
-----------------------------------------------------
City | KIHEI
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96753-8065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-463-9932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PENNY HARRIS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 979-218-2274
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1362
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------