=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568675684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN E EGSTAD D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 07/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 417 N MAIN ST
-----------------------------------------------------
City | BONHAM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75418-4322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-583-7411
-----------------------------------------------------
Fax | 903-583-9601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 N MAIN ST
-----------------------------------------------------
City | BONHAM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75418-4322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-583-7411
-----------------------------------------------------
Fax | 903-583-9601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 005252
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------