Provider Demographics
NPI:1154414647
Name:FORTIER, PHIL (DC)
Entity type:Individual
Prefix:DR
First Name:PHIL
Middle Name:
Last Name:FORTIER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 E. BYRON NELSON BLVD.
Mailing Address - Street 2:A
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262
Mailing Address - Country:US
Mailing Address - Phone:817-430-8459
Mailing Address - Fax:817-491-7188
Practice Address - Street 1:509 E. BYRON NELSON BLVD.
Practice Address - Street 2:A
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262
Practice Address - Country:US
Practice Address - Phone:817-430-8459
Practice Address - Fax:817-491-7188
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6429111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX605797OtherBLUE CROSS BLUE SHIELD
TX5953432OtherAETNA
TX1797201Medicaid
TX605797OtherBLUE CROSS BLUE SHIELD
TX5953432OtherAETNA