MEDICARE: CAMELOT CHIROPRACTIC CENTRE, INC.

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	3369	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	085V8	OTHER	NC	BCB

General Provider Information

NPI Number	:	1245391366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMELOT CHIROPRACTIC CENTRE, INC.

Provider Business Mailing Address
First Line	:	4023 VILLAGE PARK DR
Second Line	:
City	:	KNIGHTDALE
State	:	NC
Zip	:	27545-7044
Country	:	US
Telephone Number	:	919-261-9444
Fax Number	:	919-261-9470

Provider Business Practice Location Address
First Line	:	4023 VILLAGE PARK DR
Second Line	:
City	:	KNIGHTDALE
State	:	NC
Zip	:	27545-7044
Country	:	US
Telephone Number	:	919-261-9444
Fax Number	:	919-261-9470

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JASON N KUCMA
Credential	:	D.C.
Telephone Number	:	919-261-9444

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	12/08/2015

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