=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962917682
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOWLING GREEN FAMILY CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2017
-----------------------------------------------------
Last Update Date | 10/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 651 US 31W BYP STE 202
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42101-4977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-904-1837
-----------------------------------------------------
Fax | 270-904-6394
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 651 US 31W BYP STE 202
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42101-4977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-904-1837
-----------------------------------------------------
Fax | 270-904-6394
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COMPLIANCE OFFICER
-----------------------------------------------------
Name | TOSHA MCCORMACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 859-408-5440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------