=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326172289
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY LYN WIRTANEN D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1961 W T C JESTER BLVD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77008-1256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-868-3223
-----------------------------------------------------
Fax | 713-868-1413
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1606 BAYRAM DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77055-3216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-468-7510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6607
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------