Healthcare Provider Details

I. General information

NPI: 1134248271
Provider Name (Legal Business Name): BRENT BULTEMEIER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3207 NEW BOSTON ROAD
TEXARKANA TX
75501
US

IV. Provider business mailing address

3207 NEW BOSTON ROAD
TEXARKANA TX
75501
US

V. Phone/Fax

Practice location:
  • Phone: 903-832-8765
  • Fax: 903-832-6060
Mailing address:
  • Phone: 903-832-8765
  • Fax: 903-832-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5532
License Number StateTX

VIII. Authorized Official

Name: DR. BRENT STEWART BULTEMEIER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 903-832-8765