=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144321795
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHOUNSAVATH ANDY PHILACNACK CHIROPRACTOR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2334 W BUCKINGHAM #360
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-272-7788
-----------------------------------------------------
Fax | 972-272-0088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2334 W BUCKINGHAM #360
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-272-7788
-----------------------------------------------------
Fax | 972-272-0088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 8631
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------