=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821289646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONDON CHIROPRACTIC CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2007
-----------------------------------------------------
Last Update Date | 08/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 61 E HIGH ST
-----------------------------------------------------
City | LONDON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43140-1247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-852-0717
-----------------------------------------------------
Fax | 740-852-0828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61 E HIGH ST
-----------------------------------------------------
City | LONDON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43140-1247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-852-0717
-----------------------------------------------------
Fax | 740-852-0828
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. GARY ROY GOLDSTEIN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 740-852-0717
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1117
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 1117
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------