Healthcare Provider Details

I. General information

NPI: 1114160827
Provider Name (Legal Business Name): PARK CITIES CHIROSPORT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2009
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3408 MILTON AVE
DALLAS TX
75205-1338
US

IV. Provider business mailing address

3408 MILTON AVE
DALLAS TX
75205-1338
US

V. Phone/Fax

Practice location:
  • Phone: 214-739-2225
  • Fax: 214-739-2228
Mailing address:
  • Phone: 214-739-2225
  • Fax: 214-739-2228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number09289
License Number StateTX

VIII. Authorized Official

Name: DR. R TODD PETERSEN
Title or Position: OWNER
Credential: DC
Phone: 214-739-2225