Provider Demographics
NPI:1275751471
Name:MASK, T WAYNE (DC)
Entity Type:Individual
Prefix:
First Name:T
Middle Name:WAYNE
Last Name:MASK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-2126
Mailing Address - Country:US
Mailing Address - Phone:936-544-2225
Mailing Address - Fax:936-544-2259
Practice Address - Street 1:305 S 5TH ST
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-2126
Practice Address - Country:US
Practice Address - Phone:936-544-2225
Practice Address - Fax:936-544-2259
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5173111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX603011Medicare ID - Type UnspecifiedMEDICARE NO