Provider Demographics
NPI:1679720973
Name:DR PAMELA A TACKETT DC PC
Entity Type:Organization
Organization Name:DR PAMELA A TACKETT DC PC
Other - Org Name:TACKETT CHIROPRACTIC LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CHIROP PC PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:830-379-2944
Mailing Address - Street 1:PO BOX 1567
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155
Mailing Address - Country:US
Mailing Address - Phone:830-379-2944
Mailing Address - Fax:830-303-2944
Practice Address - Street 1:1367 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155
Practice Address - Country:US
Practice Address - Phone:830-379-2944
Practice Address - Fax:830-303-2944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4350111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152916601Medicaid
TX152916601Medicaid