Provider Demographics
NPI:1750333860
Name:CANTON CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:CANTON CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-943-9431
Mailing Address - Street 1:PO BOX 3770
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-1070
Mailing Address - Country:US
Mailing Address - Phone:903-567-6106
Mailing Address - Fax:903-567-5115
Practice Address - Street 1:300 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-1439
Practice Address - Country:US
Practice Address - Phone:903-567-6106
Practice Address - Fax:906-567-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080996401Medicaid
TX00680NOtherBCBS
TX00680NMedicare PIN