MEDICARE: TEEPLE CHIROPRACTIC CLINIC, INC.

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	01-04560	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	660053	OTHER	KS	BCBS - KS GROUP #
2	31740013	OTHER	KS	BCBS - KC GROUP #

General Provider Information

NPI Number	:	1043433055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEEPLE CHIROPRACTIC CLINIC, INC.

Provider Business Mailing Address
First Line	:	PO BOX 233
Second Line	:
City	:	BASEHOR
State	:	KS
Zip	:	66007-0233
Country	:	US
Telephone Number	:	913-724-1538
Fax Number	:	913-724-3222

Provider Business Practice Location Address
First Line	:	15604 PINEHURST DR
Second Line	:	SUITE 3A
City	:	BONNER SPRINGS
State	:	KS
Zip	:	66012-8233
Country	:	US
Telephone Number	:	913-724-1538
Fax Number	:	913-724-3222

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. MICHAEL J TEEPLE
Credential	:	DC
Telephone Number	:	913-724-1538

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	02/26/2008

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