MEDICARE: COUGHLIN 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	08002463A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	08002463A	OTHER	IN	LICENSE #
2	1972837219	OTHER	IN	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1659687705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUGHLIN CHIROPRACTIC INC

Provider Business Mailing Address
First Line	:	5680 CAITO DR STE 105
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46226-1367
Country	:	US
Telephone Number	:	317-495-9882
Fax Number	:	317-495-9883

Provider Business Practice Location Address
First Line	:	5680 CAITO DR STE 105
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46226-1367
Country	:	US
Telephone Number	:	317-495-9882
Fax Number	:	317-495-9883

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SHELLEY M COUGHLIN
Credential	:	DC
Telephone Number	:	317-495-9882

Provider Enumeration Date	:	08/27/2010
Last Update Date	:	08/27/2010

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