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General NPI Number Information
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NPI Number | 1639379035
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Entity Type | Organization
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Legal Business Name | TMJ TX CLINIC
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Dates
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Enumeration Date | 07/23/2007
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Last Update Date | 07/23/2007
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Provider Practice Location Address
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Address Line | 8649 REGENCY PARK BLVD
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City | PORT RICHEY
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State | FL
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Zip | 34668-5742
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Country | US
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Telephone | 727-843-4035
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Fax | 727-817-0475
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Provider Business Mailing Address
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Address Line | 8649 REGENCY PARK BLVD
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City | PORT RICHEY
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State | FL
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Zip | 34668-5742
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Country | US
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Telephone | 727-843-4035
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Fax | 727-817-0475
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Authorized Official
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Title or Position | OWNER
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Name | MRS. INA MARIE CHANCEY
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Credential | M.S./CCC/SLP
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Telephone | 727-843-4035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SA 1638
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License Number State | FL
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