MEDICARE: BRONSON CLINIC, INC.

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	111NX0800X	Orthopedic Chiropractor	DC4065	TX

General Provider Information

NPI Number	:	1225231715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRONSON CLINIC, INC.

Provider Business Mailing Address
First Line	:	5521 BELLAIRE DR S STE 100
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5855
Country	:	US
Telephone Number	:	817-732-4441
Fax Number	:	817-732-2472

Provider Business Practice Location Address
First Line	:	5521 BELLAIRE DR S STE 100
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5855
Country	:	US
Telephone Number	:	817-732-4441
Fax Number	:	817-732-2472

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK RICHARD BRONSON
Credential	:	DC
Telephone Number	:	817-732-4441

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	08/22/2020

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