=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518332477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH ARLINGTON INJURY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2015
-----------------------------------------------------
Last Update Date | 03/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1730 W BARDIN RD STE 200
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76017-1682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-999-8105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 195884
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75219-8615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-999-8105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DAVID LONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 682-999-8105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | F0011752
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------