=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831609312
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY FAMILY CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2017
-----------------------------------------------------
Last Update Date | 10/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6377 MONROE ST
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-1429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-322-0741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6377 MONROE ST
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-1429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-322-0741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTIC PHYSICIAN
-----------------------------------------------------
Name | DR. JESSICA ANNE LOCKHART
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 419-322-0741
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301010592
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4427
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------