MEDICARE: FT RECOVERY 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

General Provider Information

NPI Number	:	1356441133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FT RECOVERY CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	10963 VAN WERT DECATUR RD
Second Line	:
City	:	VAN WERT
State	:	OH
Zip	:	45891-9211
Country	:	US
Telephone Number	:	419-238-6686
Fax Number	:	419-238-6201

Provider Business Practice Location Address
First Line	:	103 EAST BROADWAY ST
Second Line	:
City	:	FT RECOVERY
State	:	OH
Zip	:	45846-0655
Country	:	US
Telephone Number	:	419-375-4558
Fax Number	:	419-375-1002

Authorized Official
Title or Position	:	OWNER
Name	:	SHAD ALAN FOSTER
Credential	:	D.C.
Telephone Number	:	419-238-6686

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	07/23/2008

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