Provider Demographics
NPI:1790794865
Name:NIETO, JORGE LUIS (DC)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:NIETO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1003 CALGARY CT
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-2953
Mailing Address - Country:US
Mailing Address - Phone:469-353-4364
Mailing Address - Fax:
Practice Address - Street 1:6101 WINDHAVEN PKWY STE 145
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8198
Practice Address - Country:US
Practice Address - Phone:972-473-8980
Practice Address - Fax:972-212-6851
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-06
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10219111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AM291OtherBCBS OF TEXAS
TX7476907OtherAETNA
TX8F6390Medicare PIN