MEDICARE: JERRY LEE BERNEATHY 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	11853	CA

General Provider Information

NPI Number	:	1780870907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY LEE BERNEATHY D.C

Provider Business Mailing Address
First Line	:	1707 GRAND AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-4469
Country	:	US
Telephone Number	:	858-273-6700
Fax Number	:	858-273-6702

Provider Business Practice Location Address
First Line	:	1707 GRAND AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-4469
Country	:	US
Telephone Number	:	858-273-6700
Fax Number	:	858-273-6702

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

Provider Enumeration Date	:	09/20/2007
Last Update Date	:	09/21/2007

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