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General NPI Number Information
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NPI Number | 1801114533
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Entity Type | Organization
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Legal Business Name | HOOSIER SPORTS & CHIROPRACTIC LLC
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Dates
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Enumeration Date | 05/05/2010
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Last Update Date | 05/06/2010
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Provider Practice Location Address
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Address Line | 122 W WAYNE STREET
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City | FORT WAYNE
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State | IN
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Zip | 46802
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Country | US
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Telephone | 260-450-3584
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 12033
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City | FORT WAYNE
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State | IN
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Zip | 46862-2033
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Country | US
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Telephone | 260-450-3584
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. JENNIFER NUNNALLY
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Credential | DC
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Telephone | 260-450-3584
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 08002323A
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License Number State | IN
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