=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871877670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GALLAGHER CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2011
-----------------------------------------------------
Last Update Date | 09/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 506 CROCKER ST SUITE #1
-----------------------------------------------------
City | MAZOMANIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53560-9425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-795-4820
-----------------------------------------------------
Fax | 608-795-4879
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 506 CROCKER ST SUITE #1
-----------------------------------------------------
City | MAZOMANIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53560-9425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-795-4820
-----------------------------------------------------
Fax | 608-795-4879
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. MICHAEL DAVID GALLAGHER
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 608-795-4820
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 3549-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------