Provider Demographics
NPI:1609020338
Name:CHERRY LANE CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:CHERRY LANE CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-560-1625
Mailing Address - Street 1:2603 S CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-3919
Mailing Address - Country:US
Mailing Address - Phone:817-560-1625
Mailing Address - Fax:817-560-1627
Practice Address - Street 1:2603 S CHERRY LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-3919
Practice Address - Country:US
Practice Address - Phone:817-560-1625
Practice Address - Fax:817-560-1627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC3062111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX50NDOtherBLUE CROSS/BLUE SHIELD