Provider Demographics
NPI:1093917726
Name:WACO BONE & JOINT CLINIC, P.A.
Entity Type:Organization
Organization Name:WACO BONE & JOINT CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:L
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-754-0375
Mailing Address - Street 1:5100 FRANKLIN AVEUNE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-6922
Mailing Address - Country:US
Mailing Address - Phone:254-754-0375
Mailing Address - Fax:254-754-2667
Practice Address - Street 1:5100 FRANKLIN AVEUNE
Practice Address - Street 2:SUITE C
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-6922
Practice Address - Country:US
Practice Address - Phone:254-754-0375
Practice Address - Fax:254-754-2667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0833246-02Medicaid
TX00JH59Medicare PIN
CD3743Medicare PIN
TX0833246-02Medicaid