Provider Demographics
NPI:1457500035
Name:PRO-CARE SPINE CENTER, LLC
Entity Type:Organization
Organization Name:PRO-CARE SPINE CENTER, LLC
Other - Org Name:PRO-CARE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MARKETING AND OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:BOECKING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-371-7478
Mailing Address - Street 1:1015 W 39TH 1/2 ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-4005
Mailing Address - Country:US
Mailing Address - Phone:512-371-7478
Mailing Address - Fax:
Practice Address - Street 1:9502 HUEBNER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1548
Practice Address - Country:US
Practice Address - Phone:512-371-7478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9693111N00000X
TX10883111N00000X
TXN1732207R00000X
TXF9289208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L0433Medicare PIN
TX00921WMedicare PIN