Provider Demographics
NPI:1356678718
Name:HOMETOWN CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:HOMETOWN CHIROPRACTIC, PLLC
Other - Org Name:HOMETOWN CHIROPRACTIC AND REHAB
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCIAL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-875-8676
Mailing Address - Street 1:2200 W ENNIS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-8054
Mailing Address - Country:US
Mailing Address - Phone:972-875-8676
Mailing Address - Fax:972-875-8481
Practice Address - Street 1:2200 W ENNIS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-8054
Practice Address - Country:US
Practice Address - Phone:972-875-8600
Practice Address - Fax:972-875-8481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2014-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9980111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX608125OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX186463901Medicaid
TXPOO389949OtherRAIL ROAD MEDICARE
TXVO8429Medicare UPIN
TX186463901Medicaid