MEDICARE: WABASH VALLEY CHIROPRACTIC

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	08001705A	IN

General Provider Information

NPI Number	:	1407028806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WABASH VALLEY CHIROPRACTIC

Provider Business Mailing Address
First Line	:	4211 E 3RD ST
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-5550
Country	:	US
Telephone Number	:	812-323-0700
Fax Number	:	812-323-0702

Provider Business Practice Location Address
First Line	:	4211 E 3RD ST
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-5550
Country	:	US
Telephone Number	:	812-323-0700
Fax Number	:	812-323-0702

Authorized Official
Title or Position	:	CHIROPRACTOR/OWNER
Name	:	DR. TRENT M ANDERSON
Credential	:	D.C.
Telephone Number	:	812-323-0700

Provider Enumeration Date	:	03/26/2008
Last Update Date	:	03/26/2008

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