MEDICARE: JESSE M COLEMAN DC

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	DC009738	PA

General Provider Information

NPI Number	:	1871618538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE M COLEMAN DC

Provider Business Mailing Address
First Line	:	647 E MAIN ST
Second Line	:	APT 72
City	:	SOMERSET
State	:	PA
Zip	:	15501
Country	:	US
Telephone Number	:	404-759-9058
Fax Number	:

Provider Business Practice Location Address
First Line	:	1802 LINCOLN WAY
Second Line	:	AGONA CHIROPRACTIC CLINIC
City	:	WHITE OAK
State	:	PA
Zip	:	15131
Country	:	US
Telephone Number	:	412-678-3844
Fax Number	:	412-346-0203

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	07/08/2007

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