Provider Demographics
NPI:1134248271
Name:BRENT BULTEMEIER PA
Entity type:Organization
Organization Name:BRENT BULTEMEIER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:BULTEMEIER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-832-8765
Mailing Address - Street 1:3207 NEW BOSTON ROAD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501
Mailing Address - Country:US
Mailing Address - Phone:903-832-8765
Mailing Address - Fax:903-832-6060
Practice Address - Street 1:3207 NEW BOSTON ROAD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501
Practice Address - Country:US
Practice Address - Phone:903-832-8765
Practice Address - Fax:903-832-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5532111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0072QDOtherBLUE CROSS BLUE SHIELD OF TX
TXDE5478OtherRAILROAD MEDICARE
TX00W368Medicare PIN