Provider Demographics
NPI:1750654984
Name:WEST TEXAS REGENERATIVE MEDICINE CLINIC
Entity Type:Organization
Organization Name:WEST TEXAS REGENERATIVE MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:E
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-367-8719
Mailing Address - Street 1:3501 S SONCY
Mailing Address - Street 2:STE 1001
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-3834
Mailing Address - Country:US
Mailing Address - Phone:806-367-8719
Mailing Address - Fax:806-418-4329
Practice Address - Street 1:1701 5TH AVE
Practice Address - Street 2:STE A
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-3834
Practice Address - Country:US
Practice Address - Phone:806-655-4878
Practice Address - Fax:806-655-8790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-19
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
TXK5914208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB155856Medicare PIN