=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376354506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CR CUSTOM CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2025
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 UNIVERSITY DR E STE E
-----------------------------------------------------
City | COLLEGE STATION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77840-1743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-446-0075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2910 BRIARCREEK CT
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-2107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-446-0075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | COLE RANDALL ROEMER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 979-446-0075
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------