MEDICARE: OMAHA SPINE AND SPORT, FUNCTIONAL CHIROPRACTIC CENTER, 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	1328	NE

General Provider Information

NPI Number	:	1407115488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMAHA SPINE AND SPORT, FUNCTIONAL CHIROPRACTIC CENTER, PC

Provider Business Mailing Address
First Line	:	15615 PACIFIC ST STE 106
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68118-2118
Country	:	US
Telephone Number	:	402-933-4447
Fax Number	:	402-933-4857

Provider Business Practice Location Address
First Line	:	15615 PACIFIC ST STE 106
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68118-2118
Country	:	US
Telephone Number	:	402-933-4447
Fax Number	:	402-933-4857

Authorized Official
Title or Position	:	CHIROPRACTOR/PRESIDENT
Name	:	DR. COREY J CAMPBELL
Credential	:	DC
Telephone Number	:	402-933-4447

Provider Enumeration Date	:	05/10/2012
Last Update Date	:	05/23/2012

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