MEDICARE: FOOTHILLS CHIROPRACTIC CLINIC PC

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	0104555784	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	VVC826A	OTHER	VA	PROVIDER PTAN
2	1396846051	OTHER	VA	PROVIDER NPI

General Provider Information

NPI Number	:	1356741318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTHILLS CHIROPRACTIC CLINIC PC

Provider Business Mailing Address
First Line	:	101 1ST ST NW
Second Line	:	SUITE 1B
City	:	PULASKI
State	:	VA
Zip	:	24301-5605
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 1ST ST NW
Second Line	:	SUITE 1B
City	:	PULASKI
State	:	VA
Zip	:	24301-5605
Country	:	US
Telephone Number	:	336-648-2725
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. HOLLY WELTY MILLER
Credential	:	D.C.
Telephone Number	:	336-648-2725

Provider Enumeration Date	:	08/27/2014
Last Update Date	:	08/27/2014

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