MEDICARE: LYNDONVILLE FAMILY CHIROPRACTIC, 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	006-0001143	VT

General Provider Information

NPI Number	:	1326254657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYNDONVILLE FAMILY CHIROPRACTIC, INC.

Provider Business Mailing Address
First Line	:	11 HILL ST
Second Line	:
City	:	LYNDONVILLE
State	:	VT
Zip	:	05851-8911
Country	:	US
Telephone Number	:	802-626-5866
Fax Number	:	802-626-0980

Provider Business Practice Location Address
First Line	:	11 HILL ST
Second Line	:
City	:	LYNDONVILLE
State	:	VT
Zip	:	05851-8911
Country	:	US
Telephone Number	:	802-626-5866
Fax Number	:	802-626-0980

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KARSON ELLSWORTH CLARK JR.
Credential	:	D.C.
Telephone Number	:	802-626-5866

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	09/09/2009

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