=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003005646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINE TIME PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2007
-----------------------------------------------------
Last Update Date | 12/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4702 NORTHWEST HWY
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75043-4912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-270-5333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4702 NORTHWEST HWY
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75043-4912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-270-5333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DENNIS WAYNE WILLIAMSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 214-563-1790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NN1001X
-----------------------------------------------------
Taxonomy Name | Nutrition Chiropractor
-----------------------------------------------------
License Number | 10235
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 10235
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 10235
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------