Provider Demographics
NPI:1770847071
Name:TEXAS CENTER OF CHIROPRACTIC ORTHOPEDICS, LLC
Entity Type:Organization
Organization Name:TEXAS CENTER OF CHIROPRACTIC ORTHOPEDICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-874-2555
Mailing Address - Street 1:6431 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76132-2777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6431 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76132-2777
Practice Address - Country:US
Practice Address - Phone:817-874-2555
Practice Address - Fax:830-238-3485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-02
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5994111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB156609Medicare PIN