MEDICARE: ACCIDENT & BACK PAIN CENTER

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	603589	OTHER		BLUE CROSS
2	179719500	OTHER		US DEPT. OF LABOR

General Provider Information

NPI Number	:	1740360932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACCIDENT & BACK PAIN CENTER

Provider Business Mailing Address
First Line	:	3304 SE LOOP 820
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-1108
Country	:	US
Telephone Number	:	817-568-9200
Fax Number	:	817-568-8792

Provider Business Practice Location Address
First Line	:	3304 SE LOOP 820
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-1108
Country	:	US
Telephone Number	:	817-568-9200
Fax Number	:	817-568-8792

Authorized Official
Title or Position	:	REPRESENTATIVE
Name	:	CINDY HAMMETT
Credential	:
Telephone Number	:	979-776-7300

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	06/13/2008

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Directions to “ACCIDENT & BACK PAIN CENTER ” Practice Location

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