Provider Demographics
NPI:1235233750
Name:COLIN TKACHUK
Entity Type:Organization
Organization Name:COLIN TKACHUK
Other - Org Name:OPTIMUM CHIROPRACTIC AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TKACHUK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-481-9339
Mailing Address - Street 1:6224 COLLEYVILLE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6276
Mailing Address - Country:US
Mailing Address - Phone:817-481-9339
Mailing Address - Fax:817-481-9669
Practice Address - Street 1:6224 COLLEYVILLE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6276
Practice Address - Country:US
Practice Address - Phone:817-481-9339
Practice Address - Fax:817-481-9669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9771111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX608079OtherBLUE CROSS BLUE SHIELD
TXP00366997OtherRAILROAD MEDICARE
TX9771OtherPROF LICENSE #
TX610900Medicare PIN