Provider Demographics
NPI:1316593551
Name:EAST TEXAS CLINIC OF CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:EAST TEXAS CLINIC OF CHIROPRACTIC, LLC
Other - Org Name:CAMP COUNTY CLINIC OF CHIROPRACTIC & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARTH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-563-9501
Mailing Address - Street 1:140 COUNTY ROAD 4425
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-8686
Mailing Address - Country:US
Mailing Address - Phone:903-563-9501
Mailing Address - Fax:
Practice Address - Street 1:210 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:TX
Practice Address - Zip Code:75686-1630
Practice Address - Country:US
Practice Address - Phone:903-563-9501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty