Provider Demographics
NPI:1003117052
Name:FT. WORTH SPINAL DECOMPRESSION CENTER, P.C.
Entity type:Organization
Organization Name:FT. WORTH SPINAL DECOMPRESSION CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:WULLAERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-284-1235
Mailing Address - Street 1:1149 PRECINCT LINE RD STE A
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-4289
Mailing Address - Country:US
Mailing Address - Phone:817-284-1235
Mailing Address - Fax:817-284-1226
Practice Address - Street 1:1149 PRECINCT LINE RD STE A
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-4289
Practice Address - Country:US
Practice Address - Phone:817-284-1235
Practice Address - Fax:817-284-1226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6533111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty