=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134267867
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2007
-----------------------------------------------------
Last Update Date | 06/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1108 W PARKER RD SUITE 110
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75075-4000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-422-5223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 866124
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75086-6124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-422-5223
-----------------------------------------------------
Fax | 972-422-5791
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. JACQUELINE DUSEK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-422-5223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 9505
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | E0056
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------