Provider Demographics
NPI:1013196997
Name:BRACE CHIROPRACTIC AND WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:BRACE CHIROPRACTIC AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:POLK
Authorized Official - Last Name:BRACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-444-2170
Mailing Address - Street 1:237 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3177
Mailing Address - Country:US
Mailing Address - Phone:817-444-2170
Mailing Address - Fax:817-270-3338
Practice Address - Street 1:237 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3177
Practice Address - Country:US
Practice Address - Phone:817-444-2170
Practice Address - Fax:817-270-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9732111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8R3130OtherBLUE CROSS BLUE SHIELD
TX8R3130OtherBLUE CROSS BLUE SHIELD
TX00688XMedicare PIN
TXV02376Medicare UPIN