MEDICARE: SOUTH TEXAS BACK 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	111N00000X	Chiropractor	5449	TX
2	363LF0000X	Family Nurse Practitioner	F0914439	TX
3	111N00000X	Chiropractor	11212	TX

General Provider Information

NPI Number	:	1376835736
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH TEXAS BACK CLINIC INC

Provider Business Mailing Address
First Line	:	9114 MCPHERSON ROAD
Second Line	:	SUITE 2505
City	:	LAREDO
State	:	TX
Zip	:	78045-6511
Country	:	US
Telephone Number	:	956-726-9886
Fax Number	:	956-722-1590

Provider Business Practice Location Address
First Line	:	9114 MCPHERSON ROAD
Second Line	:	SUITE 2505
City	:	LAREDO
State	:	TX
Zip	:	78045-6511
Country	:	US
Telephone Number	:	956-726-9886
Fax Number	:	956-722-1590

Authorized Official
Title or Position	:	MANAGER/CEO
Name	:	MR. F QUINN LEWIS
Credential	:
Telephone Number	:	325-513-1703

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	11/25/2014

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