MEDICARE: THREE FOUNTAINS 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	2108	SC

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	:	1679560742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THREE FOUNTAINS CHIROPRACTIC, INC.

Provider Business Mailing Address
First Line	:	PO BOX 84428
Second Line	:	1926 SOUTH LAKE DRIVE
City	:	LEXINGTON
State	:	SC
Zip	:	29073-0008
Country	:	US
Telephone Number	:	803-808-1897
Fax Number	:	803-808-1297

Provider Business Practice Location Address
First Line	:	1926 S LAKE DR
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29073-8282
Country	:	US
Telephone Number	:	803-808-1897
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID R GOOLDY
Credential	:	DC
Telephone Number	:	803-808-1897

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	08/24/2007

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