MEDICARE: JOSHUA CHIROPRACTIC 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	4810	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0057MU	OTHER	TX	BCBS GROUP

General Provider Information

NPI Number	:	1427063395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSHUA CHIROPRACTIC PLLC

Provider Business Mailing Address
First Line	:	611 N BROADWAY ST
Second Line	:
City	:	JOSHUA
State	:	TX
Zip	:	76058-6155
Country	:	US
Telephone Number	:	817-484-2707
Fax Number	:	817-484-2706

Provider Business Practice Location Address
First Line	:	611 N BROADWAY ST
Second Line	:
City	:	JOSHUA
State	:	TX
Zip	:	76058-6155
Country	:	US
Telephone Number	:	817-484-2707
Fax Number	:	817-484-2706

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. SIDNEY CHARLES PRUITT III
Credential	:	DC
Telephone Number	:	817-645-8116

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	08/22/2020

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