Provider Demographics
NPI:1053635854
Name:STAFFORD CHIROPRACTIC SPORT AND WELLNESS INC.
Entity Type:Organization
Organization Name:STAFFORD CHIROPRACTIC SPORT AND WELLNESS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:FELKER
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-499-2424
Mailing Address - Street 1:1367 SUGAR CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3989
Mailing Address - Country:US
Mailing Address - Phone:281-499-2424
Mailing Address - Fax:281-499-6525
Practice Address - Street 1:2434 S MAIN ST
Practice Address - Street 2:A
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-5522
Practice Address - Country:US
Practice Address - Phone:281-499-2424
Practice Address - Fax:281-499-6525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2247111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A6165Medicare PIN