=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982046728
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OGLE CHIROPRACTIC AND REHAB CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2013
-----------------------------------------------------
Last Update Date | 11/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 LAFAYETTE CIR STE A
-----------------------------------------------------
City | WAYNESVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65583-2430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-774-4177
-----------------------------------------------------
Fax | 573-774-3912
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 LAFAYETTE CIR STE A
-----------------------------------------------------
City | WAYNESVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65583-2430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-774-4177
-----------------------------------------------------
Fax | 573-774-3912
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHANE RANDALL OGLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-774-4177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------