MEDICARE: CHIROPRACTIC SPORTS & WELLNESS PC

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	650	WY

General Provider Information

NPI Number	:	1114216082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIROPRACTIC SPORTS & WELLNESS PC

Provider Business Mailing Address
First Line	:	1021 E LINCOLNWAY
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82001-4851
Country	:	US
Telephone Number	:	307-635-7727
Fax Number	:	307-638-0423

Provider Business Practice Location Address
First Line	:	1021 E LINCOLNWAY
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82001-4851
Country	:	US
Telephone Number	:	307-635-7727
Fax Number	:	307-638-0423

Authorized Official
Title or Position	:	OWNER
Name	:	PAUL ROMEO CASSISTA
Credential	:	D.C.
Telephone Number	:	307-635-7727

Provider Enumeration Date	:	03/31/2011
Last Update Date	:	03/31/2011

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