=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952642894
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAURICE K. FRETTY CHIROPRACTIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2013
-----------------------------------------------------
Last Update Date | 03/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2549 OCEAN AVE
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94132-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-841-0115
-----------------------------------------------------
Fax | 415-841-1710
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2549 OCEAN AVE
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94132-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-841-0115
-----------------------------------------------------
Fax | 415-841-1710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CHIROPRACTOR
-----------------------------------------------------
Name | DR. MAURICE K FRETTY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 415-841-0115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC25970
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------