=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619276359
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTICELLO CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2011
-----------------------------------------------------
Last Update Date | 03/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2701 W BERRY ST STE. 130
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-2360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-336-9355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 471669
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76147-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-336-9355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. NORMA ESTELLA ESPARZA
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 817-336-9355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6364
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------