=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629299136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRWAY CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 FAIRWAY DR SUITE 2A
-----------------------------------------------------
City | ALVIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77511-4661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-331-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 GLADE BRIDGE LN
-----------------------------------------------------
City | DICKINSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77539-4162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-309-0776
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. ROSS ALLEN LEAGO III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-331-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 9862
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------