MEDICARE: ELIZABETH VICTORIA HACKLEMAN D.C.

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	006634	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	350054223	OTHER	MO	RRMM
2	10851251	OTHER	MO	CAQH CREDENTIALING
3	4401089	OTHER	MO	UHC
4	5464712	OTHER	MO	AETNA
5	24778022	OTHER	MO	BCBS KC

General Provider Information

NPI Number	:	1710989694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH VICTORIA HACKLEMAN D.C.

Provider Business Mailing Address
First Line	:	2867 HIGHWAY 35 NORTH
Second Line	:
City	:	ROCKPORT
State	:	TX
Zip	:	78382
Country	:	US
Telephone Number	:	816-716-7144
Fax Number	:

Provider Business Practice Location Address
First Line	:	2867 HIGHWAY 35 NORTH
Second Line	:
City	:	ROCKPORT
State	:	TX
Zip	:	78382
Country	:	US
Telephone Number	:	816-716-7144
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	06/02/2011

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