=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184068538
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARROLLTON INJURY REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2013
-----------------------------------------------------
Last Update Date | 04/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2008 E HEBRON PKWY STE 130
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75007-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-428-3905
-----------------------------------------------------
Fax | 972-428-3910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2008 E HEBRON PKWY STE 130
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75007-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-428-3905
-----------------------------------------------------
Fax | 972-428-3910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | MR. DAVID ALFORD LONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-576-3136
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | F0010373
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------