Provider Demographics
NPI:1437220985
Name:BOULDIN, SANDRA RANEE (DC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:RANEE
Last Name:BOULDIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 S COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:COLEMAN
Mailing Address - State:TX
Mailing Address - Zip Code:76834-5018
Mailing Address - Country:US
Mailing Address - Phone:325-625-4163
Mailing Address - Fax:325-625-2065
Practice Address - Street 1:1606 S COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:COLEMAN
Practice Address - State:TX
Practice Address - Zip Code:76834-5018
Practice Address - Country:US
Practice Address - Phone:325-625-4163
Practice Address - Fax:325-625-2065
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5266111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0015059Medicaid
TX603137Medicare ID - Type UnspecifiedPROVIDOR NUMBER
TX0015059Medicaid