Provider Demographics
NPI:1336601947
Name:FAMILY HEALTH & SPINAL REJUVENATION CLINIC LLC
Entity Type:Organization
Organization Name:FAMILY HEALTH & SPINAL REJUVENATION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SHEDRACK
Authorized Official - Middle Name:
Authorized Official - Last Name:RAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-629-1027
Mailing Address - Street 1:PO BOX 2210
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-7021
Mailing Address - Country:US
Mailing Address - Phone:855-326-3644
Mailing Address - Fax:
Practice Address - Street 1:1233 E PLEASANT RUN RD STE B
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4200
Practice Address - Country:US
Practice Address - Phone:855-326-3644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty