=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528483120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LBJ PAIN AND INJURY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2014
-----------------------------------------------------
Last Update Date | 02/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9401 LBJ FWY SUITE 325
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75243-4546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-575-7771
-----------------------------------------------------
Fax | 214-575-7772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9401 LBJ FWY SUITE 325
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75243-4546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-575-7771
-----------------------------------------------------
Fax | 214-575-7772
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIO ALBERTO RODRIGUEZ
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 972-859-0524
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 9714
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------