=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780340158
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEH CHIRO PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2021
-----------------------------------------------------
Last Update Date | 12/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 W PINE ST
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72150-2443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-600-1213
-----------------------------------------------------
Fax | 501-747-1044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 178 GRANT 441
-----------------------------------------------------
City | PRATTSVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72129-9006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-942-6153
-----------------------------------------------------
Fax | 501-747-1044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | DR. TYLER E HICKS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 870-942-6153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------