MEDICARE: DR. MICAH BONNETT MORDECAI 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	111NX0100X	Occupational Health Chiropractor	6236	TX

General Provider Information

NPI Number	:	1124188602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICAH BONNETT MORDECAI D.C.

Provider Business Mailing Address
First Line	:	200 W STATE HIGHWAY 6 STE 607
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76712-3984
Country	:	US
Telephone Number	:	254-751-1606
Fax Number	:	866-571-1622

Provider Business Practice Location Address
First Line	:	200 W STATE HIGHWAY 6 STE 607
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76712-3984
Country	:	US
Telephone Number	:	254-751-1606
Fax Number	:	866-571-1622

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	07/07/2010

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