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General NPI Number Information
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NPI Number | 1376815597
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Entity Type | Organization
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Legal Business Name | COLLECTIVE CHIROPRACTIC AND REHAB INC
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Dates
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Enumeration Date | 02/03/2012
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Last Update Date | 03/28/2023
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Provider Practice Location Address
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Address Line | 509 E BYRON NELSON BLVD STE A
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City | ROANOKE
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State | TX
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Zip | 76262-6183
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Country | US
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Telephone | 817-490-6200
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Fax | 888-607-0662
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Provider Business Mailing Address
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Address Line | 509 E BYRON NELSON BLVD STE A
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City | ROANOKE
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State | TX
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Zip | 76262-6183
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Country | US
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Telephone | 817-490-6200
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Fax | 682-831-1200
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Authorized Official
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Title or Position | CHIROPRACTOR/ PRESIDENT
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Name | DR. RICHARD L PUCKETT
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Credential | D.C.
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Telephone | 817-490-6200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 8264
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License Number State | TX
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