Healthcare Provider Details

I. General information

NPI: 1972153641
Provider Name (Legal Business Name): LEVI DEAN SKOG DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10761 FOUNDERS WAY
FORT WORTH TX
76177-1574
US

IV. Provider business mailing address

10761 FOUNDERS WAY
FORT WORTH TX
76177-1574
US

V. Phone/Fax

Practice location:
  • Phone: 469-540-7158
  • Fax:
Mailing address:
  • Phone: 469-540-7158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08003083A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number14403
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: