Provider Demographics
NPI:1114160827
Name:PARK CITIES CHIROSPORT INC
Entity type:Organization
Organization Name:PARK CITIES CHIROSPORT INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:R
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:214-739-2225
Mailing Address - Street 1:3408 MILTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-1338
Mailing Address - Country:US
Mailing Address - Phone:214-739-2225
Mailing Address - Fax:214-739-2228
Practice Address - Street 1:3408 MILTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-1338
Practice Address - Country:US
Practice Address - Phone:214-739-2225
Practice Address - Fax:214-739-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-10
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX09289111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty