Provider Demographics
NPI:1407151897
Name:JAY HUMPHREY DC PA
Entity Type:Organization
Organization Name:JAY HUMPHREY DC PA
Other - Org Name:ROCKWALL SPINE AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-722-8800
Mailing Address - Street 1:1160 HORIZON ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032
Mailing Address - Country:US
Mailing Address - Phone:972-722-8800
Mailing Address - Fax:
Practice Address - Street 1:1160 HORIZON RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-5498
Practice Address - Country:US
Practice Address - Phone:972-722-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10730261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center