MEDICARE: EASTSIDE CHIROPRACTIC, PC

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	5482	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922163039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTSIDE CHIROPRACTIC, PC

Provider Business Mailing Address
First Line	:	3117 HANDLEY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-7012
Country	:	US
Telephone Number	:	817-457-4441
Fax Number	:	817-457-4467

Provider Business Practice Location Address
First Line	:	3117 HANDLEY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-7012
Country	:	US
Telephone Number	:	817-457-4441
Fax Number	:	817-457-4467

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAZZLE B SHRESTHA
Credential	:
Telephone Number	:	817-457-4441

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	02/24/2011

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