=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861642894
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLAKENEY FAMILY CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2008
-----------------------------------------------------
Last Update Date | 09/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10607 REA RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-6524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-841-2504
-----------------------------------------------------
Fax | 704-841-2508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10607 REA RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-6524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-841-2504
-----------------------------------------------------
Fax | 704-841-2508
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EDEN BERHE SEREKEBERHAN
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 704-841-2504
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 3326
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------