=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841622909
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED CHIROPRACTIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2013
-----------------------------------------------------
Last Update Date | 07/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1775 ARLINGTON ST STE 2
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34239-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-442-3824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1775 ARLINGTON ST STE 2
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34239-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-442-3824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RYAN TAYLOR JOHNSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 941-487-0266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH10960
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------