Provider Demographics
NPI:1639209539
Name:BRETT R. WOOD CHIROPRACTIC, P.A.
Entity Type:Organization
Organization Name:BRETT R. WOOD CHIROPRACTIC, P.A.
Other - Org Name:ULTIMATE HEALTH CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:RANDON
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-741-9355
Mailing Address - Street 1:2920 W. SOUTHLAKE BLVD
Mailing Address - Street 2:STE#110
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-741-9355
Mailing Address - Fax:817-741-9358
Practice Address - Street 1:2920 W. SOUTHLAKE BLVD
Practice Address - Street 2:STE#110
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-741-9355
Practice Address - Fax:817-741-9358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10004111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDG3247Medicare PIN
TX00Y066Medicare PIN