MEDICARE: ON THE ROAD 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

General Provider Information

NPI Number	:	1861701898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ON THE ROAD CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	4511 MAIN ST
Second Line	:
City	:	JOSEPH CITY
State	:	AZ
Zip	:	86032
Country	:	US
Telephone Number	:	928-288-9033
Fax Number	:

Provider Business Practice Location Address
First Line	:	4511 MAIN ST
Second Line	:
City	:	JOSEPH CITY
State	:	AZ
Zip	:	86032
Country	:	US
Telephone Number	:	928-288-9033
Fax Number	:

Authorized Official
Title or Position	:	OWNER MANAGER
Name	:	DR. JASON LEE MULDER
Credential	:	DC
Telephone Number	:	928-288-9033

Provider Enumeration Date	:	09/24/2010
Last Update Date	:	09/24/2010

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Directions to “ON THE ROAD CHIROPRACTIC, LLC ” Practice Location

Language	Start Address	Practice Location

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