MEDICARE: PASSIONATELY PRINCIPLED

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	261QH0100X	Health Service Clinic/Center	4152	NC

General Provider Information

NPI Number	:	1154600476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PASSIONATELY PRINCIPLED

Provider Business Mailing Address
First Line	:	12324 HAYMARKET RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28214-9209
Country	:	US
Telephone Number	:	770-712-5719
Fax Number	:

Provider Business Practice Location Address
First Line	:	2550 W ARROWOOD RD
Second Line	:	SUITE 104
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-6651
Country	:	US
Telephone Number	:	770-712-5719
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DREW-MONTEZ CLARK
Credential	:
Telephone Number	:	770-712-5719

Provider Enumeration Date	:	08/04/2011
Last Update Date	:	08/04/2011

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Directions to “PASSIONATELY PRINCIPLED ” Practice Location

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