Provider Demographics
NPI:1790971778
Name:FAMILY MEDICAL & URGENT CARE CENTER PA
Entity Type:Organization
Organization Name:FAMILY MEDICAL & URGENT CARE CENTER PA
Other - Org Name:ELLIS COUNTY BACK INSTITUTE PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR/PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:JOZEF
Authorized Official - Middle Name:P
Authorized Official - Last Name:VERHAERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-937-0086
Mailing Address - Street 1:905 FERRIS AVE
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-2556
Mailing Address - Country:US
Mailing Address - Phone:972-937-0086
Mailing Address - Fax:972-923-2351
Practice Address - Street 1:905 FERRIS AVE
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2556
Practice Address - Country:US
Practice Address - Phone:972-937-0086
Practice Address - Fax:972-923-2351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5723111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6440750001Medicare NSC
TX00862TMedicare PIN