MEDICARE: CHERRY LANE CHIROPRACTIC, INC.

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	DC3062	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50ND	OTHER	TX	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1609020338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHERRY LANE CHIROPRACTIC, INC.

Provider Business Mailing Address
First Line	:	2603 S CHERRY LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-3919
Country	:	US
Telephone Number	:	817-560-1625
Fax Number	:	817-560-1627

Provider Business Practice Location Address
First Line	:	2603 S CHERRY LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-3919
Country	:	US
Telephone Number	:	817-560-1625
Fax Number	:	817-560-1627

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN MICHAEL SCOTT
Credential	:	D.C.
Telephone Number	:	817-560-1625

Provider Enumeration Date	:	11/07/2008
Last Update Date	:	11/07/2008

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Directions to “CHERRY LANE CHIROPRACTIC, INC. ” Practice Location

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