Provider Demographics
NPI:1699893230
Name:EAST TEXAS CHIROPRACTIC OF JASPER, PA
Entity type:Organization
Organization Name:EAST TEXAS CHIROPRACTIC OF JASPER, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIC
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LANGFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:409-384-7776
Mailing Address - Street 1:799 W. GIBSON
Mailing Address - Street 2:STE 700
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75948
Mailing Address - Country:US
Mailing Address - Phone:409-384-7776
Mailing Address - Fax:409-384-7779
Practice Address - Street 1:799 W. GIBSON
Practice Address - Street 2:STE 700
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75948
Practice Address - Country:US
Practice Address - Phone:409-384-7776
Practice Address - Fax:409-384-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC6063111N00000X
TX11267111N00000X
TX11268111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDC6063OtherSTATE LICENSE NUMBER
TX0884470-01Medicaid
TXDC6063OtherSTATE LICENSE NUMBER
TXU43919Medicare UPIN