MEDICARE: CANTON INJURY CENTER 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

General Provider Information

NPI Number	:	1326459140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANTON INJURY CENTER LLC

Provider Business Mailing Address
First Line	:	3410 TUSC ST W FL 1
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-5639
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3410 TUSC ST W FL 1
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-5639
Country	:	US
Telephone Number	:	330-454-0400
Fax Number	:

Authorized Official
Title or Position	:	INCORPORATOR
Name	:	PHILIP TASSI
Credential	:
Telephone Number	:	330-454-0400

Provider Enumeration Date	:	05/14/2014
Last Update Date	:	05/14/2014

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