MEDICARE: NATIONAL CHIROPRACTIC, LLC

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	3364	WI

General Provider Information

NPI Number	:	1235398272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATIONAL CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	5800 W NATIONAL AVE
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53214-3446
Country	:	US
Telephone Number	:	414-431-0936
Fax Number	:

Provider Business Practice Location Address
First Line	:	5800 W NATIONAL AVE
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53214-3446
Country	:	US
Telephone Number	:	414-431-0936
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRIAN FORMOLO
Credential	:	DC
Telephone Number	:	414-431-0936

Provider Enumeration Date	:	06/05/2008
Last Update Date	:	06/05/2008

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