Provider Demographics
NPI:1922163039
Name:EASTSIDE CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:EASTSIDE CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAZZLE
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHRESTHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-457-4441
Mailing Address - Street 1:3117 HANDLEY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-7012
Mailing Address - Country:US
Mailing Address - Phone:817-457-4441
Mailing Address - Fax:817-457-4467
Practice Address - Street 1:3117 HANDLEY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-7012
Practice Address - Country:US
Practice Address - Phone:817-457-4441
Practice Address - Fax:817-457-4467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5482111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1747230Medicaid
TX1747230Medicaid
U44753Medicare UPIN