MEDICARE: DR. JACK MARTIN BOURLA D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC25312	CA

General Provider Information

NPI Number	:	1013055755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK MARTIN BOURLA D.C.

Provider Business Mailing Address
First Line	:	499 SEAPORT CT
Second Line	:	SUITE 101
City	:	REDWOOD CITY
State	:	CA
Zip	:	94063-2783
Country	:	US
Telephone Number	:	650-365-1473
Fax Number	:	650-365-1474

Provider Business Practice Location Address
First Line	:	499 SEAPORT CT
Second Line	:	SUITE 101
City	:	REDWOOD CITY
State	:	CA
Zip	:	94063-2783
Country	:	US
Telephone Number	:	650-365-1473
Fax Number	:	650-365-1474

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	07/08/2007

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