MEDICARE: BRIDGEPORT FAMILY 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	764	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548350747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEPORT FAMILY CHIROPRACTIC

Provider Business Mailing Address
First Line	:	150 EAST PHILADELPHIA AVE
Second Line	:
City	:	BRIDGEPORT
State	:	WV
Zip	:	26330-1520
Country	:	US
Telephone Number	:	304-842-7678
Fax Number	:	304-842-5973

Provider Business Practice Location Address
First Line	:	150 EAST PHILADELPHIA AVE
Second Line	:
City	:	BRIDGEPORT
State	:	WV
Zip	:	26330-1520
Country	:	US
Telephone Number	:	304-842-7678
Fax Number	:	304-842-5973

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JASON EDWARD LABENNE
Credential	:	DC
Telephone Number	:	304-842-7678

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	11/12/2014

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Directions to “BRIDGEPORT FAMILY CHIROPRACTIC ” Practice Location

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