=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871763763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TILLEY CHIROPRACTIC AND SPORTS INJURY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2008
-----------------------------------------------------
Last Update Date | 06/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 DAVIS ST SUITE B
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-951-1183
-----------------------------------------------------
Fax | 540-951-1138
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 825 DAVIS ST SUITE B
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-951-1183
-----------------------------------------------------
Fax | 540-951-1138
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GREGORY K. TILLEY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 540-951-1183
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104001844
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------