MEDICARE: GEORGE LYNN BARDWELL 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	111NN1001X	Nutrition Chiropractor	898	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	860363015	OTHER	AZ	FED I D #

General Provider Information

NPI Number	:	1295937589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE LYNN BARDWELL D.C.

Provider Business Mailing Address
First Line	:	706 N GRAND CANYON BLVD
Second Line	:
City	:	WILLIAMS
State	:	AZ
Zip	:	86046-2016
Country	:	US
Telephone Number	:	928-635-9115
Fax Number	:	928-635-9115

Provider Business Practice Location Address
First Line	:	706 N GRAND CANYON BLVD.
Second Line	:
City	:	WILLIAMS
State	:	AZ
Zip	:	86046-2200
Country	:	US
Telephone Number	:	928-635-9115
Fax Number	:	928-635-9115

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

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	06/07/2012

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