Provider Demographics
NPI:1942446547
Name:WESTSIDE SPINE AND REHAB
Entity Type:Organization
Organization Name:WESTSIDE SPINE AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCREERY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-738-6668
Mailing Address - Street 1:1300 W ROSEDALE ST
Mailing Address - Street 2:STE. C
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2826
Mailing Address - Country:US
Mailing Address - Phone:817-738-6668
Mailing Address - Fax:817-737-2541
Practice Address - Street 1:1300 W ROSEDALE ST STE C
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2824
Practice Address - Country:US
Practice Address - Phone:817-738-6668
Practice Address - Fax:817-737-2541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-02
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8520111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00834RMedicare UPIN
TX8708NUMedicare UPIN