Provider Demographics
NPI:1760515373
Name:ANGELO BACK & REHAB, PA
Entity Type:Organization
Organization Name:ANGELO BACK & REHAB, PA
Other - Org Name:ANGELO BACK & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:325-949-1600
Mailing Address - Street 1:3950 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-5622
Mailing Address - Country:US
Mailing Address - Phone:325-949-1600
Mailing Address - Fax:325-944-3754
Practice Address - Street 1:3950 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-5622
Practice Address - Country:US
Practice Address - Phone:325-949-1600
Practice Address - Fax:325-944-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4939111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F5111OtherBCBS
TX001442501Medicaid
TX8F5111OtherBCBS