Healthcare Provider Details

I. General information

NPI: 1215126909
Provider Name (Legal Business Name): JAY BOB HANEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 W 3RD ST
PECOS TX
79772-2826
US

IV. Provider business mailing address

1309 W 3RD ST
PECOS TX
79772-2826
US

V. Phone/Fax

Practice location:
  • Phone: 432-445-4878
  • Fax: 432-445-4835
Mailing address:
  • Phone: 432-445-4878
  • Fax: 432-445-4835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8354
License Number StateTX

VIII. Authorized Official

Name: DR. JAY BOB HANEY
Title or Position: OWNER
Credential: D.C.
Phone: 432-445-4878