Provider Demographics
NPI:1285798371
Name:CHIRODOCTOR P A
Entity type:Organization
Organization Name:CHIRODOCTOR P A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:G
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-867-7463
Mailing Address - Street 1:16135 PRESTON RD
Mailing Address - Street 2:STE. 127, BOX 37
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-3599
Mailing Address - Country:US
Mailing Address - Phone:972-867-7463
Mailing Address - Fax:
Practice Address - Street 1:16135 PRESTON RD
Practice Address - Street 2:STE. 127
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-3599
Practice Address - Country:US
Practice Address - Phone:972-867-7463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9263111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00650UMedicare ID - Type Unspecified
U93596Medicare UPIN
8A3018Medicare ID - Type Unspecified