Provider Demographics
NPI:1265022859
Name:JEFFREY C. PEDERSEN, D.C.
Entity Type:Organization
Organization Name:JEFFREY C. PEDERSEN, D.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-277-1111
Mailing Address - Street 1:2920 W PARK ROW DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PANTEGO
Mailing Address - State:TX
Mailing Address - Zip Code:76013-2054
Mailing Address - Country:US
Mailing Address - Phone:817-277-1111
Mailing Address - Fax:817-861-4593
Practice Address - Street 1:2920 W PARK ROW DR STE 100
Practice Address - Street 2:
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-2054
Practice Address - Country:US
Practice Address - Phone:817-277-1111
Practice Address - Fax:817-861-4593
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFREY C. PEDERSEN, D.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty