Provider Demographics
NPI:1881941607
Name:ADVANCED CHIROPRACTIC
Entity type:Organization
Organization Name:ADVANCED CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, DC
Authorized Official - Phone:936-560-5441
Mailing Address - Street 1:1602 E STARR AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4312
Mailing Address - Country:US
Mailing Address - Phone:936-560-5441
Mailing Address - Fax:936-560-5428
Practice Address - Street 1:1602 E STARR AVE STE 201
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4312
Practice Address - Country:US
Practice Address - Phone:936-560-5441
Practice Address - Fax:936-560-5428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC5020111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001454001Medicaid
TX602070Medicare PIN
TX5020Medicare UPIN