Provider Demographics
NPI:1174634265
Name:ELM STREET CHIROPRACTIC PC
Entity Type:Organization
Organization Name:ELM STREET CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER TREATING DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KALED
Authorized Official - Middle Name:
Authorized Official - Last Name:JAWHARI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:940-566-6645
Mailing Address - Street 1:1010 N ELM
Mailing Address - Street 2:STE C
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201
Mailing Address - Country:US
Mailing Address - Phone:940-566-6645
Mailing Address - Fax:940-566-6634
Practice Address - Street 1:1010 N ELM
Practice Address - Street 2:STE C
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201
Practice Address - Country:US
Practice Address - Phone:940-566-6645
Practice Address - Fax:940-566-6634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9274111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U92987Medicare UPIN
TX00471UMedicare ID - Type Unspecified