=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972948149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WICHITA CHIROPRACTIC CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2013
-----------------------------------------------------
Last Update Date | 05/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1999 N AMIDON AVE STE 224
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67203-2123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-838-8883
-----------------------------------------------------
Fax | 316-838-8884
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1999 N AMIDON AVE STE 224
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67203-2123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-838-8883
-----------------------------------------------------
Fax | 316-838-8884
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF CHIROPRACTIC
-----------------------------------------------------
Name | DR. JUAN MARTINEZ JR.
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 316-838-8883
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0105475
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------