Provider Demographics
NPI:1760830566
Name:MEDCHIRO INJURY REHAB LLC
Entity Type:Organization
Organization Name:MEDCHIRO INJURY REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-865-9248
Mailing Address - Street 1:PO BOX 195884
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-8615
Mailing Address - Country:US
Mailing Address - Phone:214-865-9248
Mailing Address - Fax:469-533-0307
Practice Address - Street 1:1619 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215
Practice Address - Country:US
Practice Address - Phone:214-865-9248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-02
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0011931111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF0011931OtherTEXAS BOARD OF CHIROPRACTIC EXAMINERS