Provider Demographics
NPI:1861493694
Name:PERISH, JUSTIN CLIVE (DC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CLIVE
Last Name:PERISH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 ROCKBROOK
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087
Mailing Address - Country:US
Mailing Address - Phone:972-832-1781
Mailing Address - Fax:972-698-8934
Practice Address - Street 1:821 SOUTH MAIN STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494
Practice Address - Country:US
Practice Address - Phone:903-342-5261
Practice Address - Fax:903-342-5661
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC5689111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX603456OtherBCBS-TX
TX0811077-01Medicaid
TX603456OtherBCBS-TX