=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831335595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATHENS CLINIC OF CHIROPRACTIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2008
-----------------------------------------------------
Last Update Date | 01/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 CONGRESS PKWY N
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37303-1618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-746-4544
-----------------------------------------------------
Fax | 423-746-4545
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 CONGRESS PKWY N
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37303-1618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-746-4544
-----------------------------------------------------
Fax | 423-746-4545
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTIC PHYSICIAN
-----------------------------------------------------
Name | DR. LUCILLE DIETRICK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 423-746-4544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC0000001348
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------