MEDICARE: DALLAS INJURY REHAB LLC

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	111NR0400X	Rehabilitation Chiropractor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8U8530	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1598969248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DALLAS INJURY REHAB LLC

Provider Business Mailing Address
First Line	:	PO BOX 600084
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75360-0084
Country	:	US
Telephone Number	:	214-357-7875
Fax Number	:	972-557-7001

Provider Business Practice Location Address
First Line	:	320 REGAL ROW
Second Line	:	SUITE 100
City	:	DALLAS
State	:	TX
Zip	:	75247-5200
Country	:	US
Telephone Number	:	214-357-7875
Fax Number	:	972-557-7001

Authorized Official
Title or Position	:	PROPRIETOR
Name	:	NICHOLAS MIRRO
Credential	:	D.C.
Telephone Number	:	214-357-7875

Provider Enumeration Date	:	06/14/2007
Last Update Date	:	10/13/2009

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