=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710088430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STOLBA CHIROPRACTIC CENTER P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 507 MAIN ST
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75501-5503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-794-7981
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 507 MAIN ST
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75501-5503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-794-7981
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MICHAEL DALE STOLBA
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 903-794-7981
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1623
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 9041
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------