MEDICARE: DR. KODY BERRONG 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	2016002123	MO

General Provider Information

NPI Number	:	1063871903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KODY BERRONG D.C.

Provider Business Mailing Address
First Line	:	2725 N WESTWOOD BLVD STE 13
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-2367
Country	:	US
Telephone Number	:	573-776-7246
Fax Number	:	844-270-7119

Provider Business Practice Location Address
First Line	:	2725 N WESTWOOD BLVD STE 13
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-2367
Country	:	US
Telephone Number	:	573-776-7246
Fax Number	:	844-270-7119

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

Provider Enumeration Date	:	02/21/2016
Last Update Date	:	05/19/2016

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