MEDICARE: 96TH STREET CHIROPRACTIC, LLC

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	08001549A	IN

General Provider Information

NPI Number	:	1710124631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	96TH STREET CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	PO BOX 501608
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9598 ALLISONVILLE ROAD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250
Country	:	US
Telephone Number	:	317-598-9696
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR/ OWNER
Name	:	MICHAEL FLYNN
Credential	:	D.C.
Telephone Number	:	317-598-9696

Provider Enumeration Date	:	01/14/2009
Last Update Date	:	04/25/2014

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