=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821143009
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNA CHIRO MED, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 02/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2424 AIRWAY DR SUITE B
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42103-7125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-746-9400
-----------------------------------------------------
Fax | 270-746-0240
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2424 AIRWAY DR SUITE B
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42103-7125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-746-9400
-----------------------------------------------------
Fax | 270-746-0240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. KELLI BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-746-9400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4950
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------