MEDICARE: PRO-CARE SPINE CENTER, PLLC

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
2	208D00000X	General Practice Physician		TX

General Provider Information

NPI Number	:	1407395353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO-CARE SPINE CENTER, PLLC

Provider Business Mailing Address
First Line	:	1015 W 39TH 1/2 ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78756-4005
Country	:	US
Telephone Number	:	512-371-7478
Fax Number	:	512-371-3861

Provider Business Practice Location Address
First Line	:	9727 POTEET JOURDANTON FWY
Second Line	:	SUITE 101
City	:	SAN ANTONIO
State	:	TX
Zip	:	78211-4574
Country	:	US
Telephone Number	:	210-881-0630
Fax Number	:	210-641-1608

Authorized Official
Title or Position	:	CEO
Name	:	GARLAND BRENT BOECKING
Credential	:
Telephone Number	:	512-371-7478

Provider Enumeration Date	:	02/13/2017
Last Update Date	:	02/13/2017

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