Provider Demographics
NPI:1962772582
Name:MEADOW CREST CHIROPRACTIC SPORTS REHAB CLINIC PLLC
Entity type:Organization
Organization Name:MEADOW CREST CHIROPRACTIC SPORTS REHAB CLINIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:VAUGHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BROZEK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:817-581-5959
Mailing Address - Street 1:PO BOX 821099
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76182-1099
Mailing Address - Country:US
Mailing Address - Phone:817-581-5959
Mailing Address - Fax:817-849-1011
Practice Address - Street 1:6709 MEADOW CREST DR
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-6669
Practice Address - Country:US
Practice Address - Phone:817-581-5959
Practice Address - Fax:817-849-1011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC6838111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU64607Medicare UPIN