MEDICARE: STATOM 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

General Provider Information

NPI Number	:	1720479827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATOM CHIROPRACTIC INC

Provider Business Mailing Address
First Line	:	2210 MEADOW DR
Second Line	:	SUITE 5
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-1323
Country	:	US
Telephone Number	:	502-822-1668
Fax Number	:	844-295-2789

Provider Business Practice Location Address
First Line	:	2210 MEADOW DR
Second Line	:	SUITE 5
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-1323
Country	:	US
Telephone Number	:	502-822-1668
Fax Number	:	844-295-2789

Authorized Official
Title or Position	:	OWNER
Name	:	KEVIN M STATOM
Credential	:	DC
Telephone Number	:	502-822-1668

Provider Enumeration Date	:	02/10/2015
Last Update Date	:	02/10/2015

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Directions to “STATOM CHIROPRACTIC INC ” Practice Location

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