=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861779977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POSTURE AND SPINE CARE CENTER SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2011
-----------------------------------------------------
Last Update Date | 11/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2031 S WEBSTER AVE SUITE A
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54301-2257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-437-3370
-----------------------------------------------------
Fax | 920-437-6212
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2031 S WEBSTER AVE SUITE A
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54301-2257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-437-3370
-----------------------------------------------------
Fax | 920-437-6212
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRIAN T DOVORANY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 920-437-3370
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 3416
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------