Provider Demographics
NPI:1497760813
Name:PRUITT, SIDNEY CHARLES III (DC)
Entity Type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:CHARLES
Last Name:PRUITT
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E LONE STAR
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76031
Mailing Address - Country:US
Mailing Address - Phone:817-645-8116
Mailing Address - Fax:817-558-8116
Practice Address - Street 1:103 E LONE STAR
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76031
Practice Address - Country:US
Practice Address - Phone:817-645-8116
Practice Address - Fax:817-558-8116
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC06019489Medicaid
TXC06019489Medicaid
TX601948Medicare PIN