MEDICARE: SPINE & SPORTS THERAPY KINGWOOD, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	12840	TX

General Provider Information

NPI Number	:	1215315270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE & SPORTS THERAPY KINGWOOD, LP

Provider Business Mailing Address
First Line	:	4295 SAN FELIPE ST
Second Line	:	SUITE 230
City	:	HOUSTON
State	:	TX
Zip	:	77027-2942
Country	:	US
Telephone Number	:	713-629-9200
Fax Number	:	713-513-5048

Provider Business Practice Location Address
First Line	:	1801 KINGWOOD DR
Second Line	:	SUITE 180
City	:	KINGWOOD
State	:	TX
Zip	:	77339-3060
Country	:	US
Telephone Number	:	713-629-9200
Fax Number	:	713-513-5048

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DANIEL DEWALCH
Credential	:	D.C., CCSP, FIAMA
Telephone Number	:	713-629-9200

Provider Enumeration Date	:	05/11/2015
Last Update Date	:	05/11/2015

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