=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811197759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREENVILLE CHIROPRACTIC CLINIC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2007
-----------------------------------------------------
Last Update Date | 07/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1654 SOUTH COLORADO STREET
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38703-7216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-335-2854
-----------------------------------------------------
Fax | 662-335-0502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1654 SOUTH COLORADO STREET
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-335-2854
-----------------------------------------------------
Fax | 662-335-0502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. CHRISTIE GALEY
-----------------------------------------------------
Credential | OM, CA
-----------------------------------------------------
Telephone | 662-335-2855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 794
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------