MEDICARE: NORTHLAND SPINE AND REHABILITATION, 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	2009013598	MO

General Provider Information

NPI Number	:	1871865550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHLAND SPINE AND REHABILITATION, LLC

Provider Business Mailing Address
First Line	:	8002 N OAK TRFY
Second Line	:	SUITE 112
City	:	KANSAS CITY
State	:	MO
Zip	:	64118-1268
Country	:	US
Telephone Number	:	816-569-5079
Fax Number	:	816-569-5298

Provider Business Practice Location Address
First Line	:	8002 N OAK TRFY
Second Line	:	SUITE 112
City	:	KANSAS CITY
State	:	MO
Zip	:	64118-1268
Country	:	US
Telephone Number	:	816-569-5079
Fax Number	:	816-569-5298

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BLAKE MITCHELL OVERLY
Credential	:	D.C.
Telephone Number	:	816-569-5079

Provider Enumeration Date	:	01/27/2012
Last Update Date	:	01/27/2012

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