MEDICARE: CHERRY BLOSSOM 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10804944	OTHER	KY	CAQH

General Provider Information

NPI Number	:	1437580115
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHERRY BLOSSOM CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	104 LAWSON DR
Second Line	:	SUITE 107
City	:	GEORGETOWN
State	:	KY
Zip	:	40324-8998
Country	:	US
Telephone Number	:	502-898-6090
Fax Number	:	859-543-0698

Provider Business Practice Location Address
First Line	:	1412 N BROADWAY
Second Line	:	SUITE 26
City	:	LEXINGTON
State	:	KY
Zip	:	40505-3157
Country	:	US
Telephone Number	:	859-543-0252
Fax Number	:	859-543-0698

Authorized Official
Title or Position	:	PHYSICIAN/CO-OWNER
Name	:	DR. JAMES T MCMONIGLE
Credential	:	DC
Telephone Number	:	502-868-6090

Provider Enumeration Date	:	12/06/2013
Last Update Date	:	12/06/2013

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