Provider Demographics
NPI:1154099596
Name:MAIN STREET INJURY CLINIC LLC
Entity Type:Organization
Organization Name:MAIN STREET INJURY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:DEHOYOS
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:817-402-9484
Mailing Address - Street 1:2100 N MAIN ST STE 105
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76164-8572
Mailing Address - Country:US
Mailing Address - Phone:817-402-9484
Mailing Address - Fax:214-853-5421
Practice Address - Street 1:2100 N MAIN ST STE 105
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76164-8572
Practice Address - Country:US
Practice Address - Phone:817-402-9484
Practice Address - Fax:214-853-5421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty