MEDICARE: DR. BRYANT LANE PONCHOT D.C.

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	08002296A	IN

General Provider Information

NPI Number	:	1508967340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYANT LANE PONCHOT D.C.

Provider Business Mailing Address
First Line	:	4625 S EMERSON AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46203-5972
Country	:	US
Telephone Number	:	317-522-2303
Fax Number	:	317-522-2304

Provider Business Practice Location Address
First Line	:	8258 ROCKVILLE RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46214-3113
Country	:	US
Telephone Number	:	317-429-5400
Fax Number	:	317-429-5401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	04/15/2013

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