=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558437095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROHEALTH SPINE CARE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 N 15TH ST SUITE 15
-----------------------------------------------------
City | CORSICANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75110-4536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-874-2211
-----------------------------------------------------
Fax | 903-874-0147
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 N 15TH ST SUITE 15
-----------------------------------------------------
City | CORSICANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75110-4536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-874-2211
-----------------------------------------------------
Fax | 903-874-0147
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C.E.O.
-----------------------------------------------------
Name | DR. DUSTIN BRICE JUDD
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 903-874-2211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 10310
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------