Provider Demographics
NPI:1043702095
Name:VALIANT LIFE MEDICAL PLLC
Entity Type:Organization
Organization Name:VALIANT LIFE MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:JERNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-926-0012
Mailing Address - Street 1:4830 SOUTH FWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-3901
Mailing Address - Country:US
Mailing Address - Phone:817-926-0012
Mailing Address - Fax:817-927-0533
Practice Address - Street 1:4830 SOUTH FWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-3901
Practice Address - Country:US
Practice Address - Phone:817-926-0012
Practice Address - Fax:817-927-0533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1889208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty