Provider Demographics
NPI:1124441506
Name:SLADE CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:SLADE CHIROPRACTIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MCCOY
Authorized Official - Last Name:SLADE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:951-805-5473
Mailing Address - Street 1:5656 WILLS CREEK LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-7626
Mailing Address - Country:US
Mailing Address - Phone:951-805-5473
Mailing Address - Fax:
Practice Address - Street 1:5656 WILLS CREEK LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-7626
Practice Address - Country:US
Practice Address - Phone:951-805-5473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12482261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center