=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861818528
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI-CITY FAMILY CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2014
-----------------------------------------------------
Last Update Date | 10/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 295 SOUTHWEST PLZ
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76016-4455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-987-6229
-----------------------------------------------------
Fax | 817-754-6639
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 295 SOUTHWEST PLZ
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76016-4455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-987-6229
-----------------------------------------------------
Fax | 817-754-6639
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF CHIROPRACTIC
-----------------------------------------------------
Name | DR. KAYLA RUTH GLOVER
-----------------------------------------------------
Credential | D.C., B.S.
-----------------------------------------------------
Telephone | 979-777-8516
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 12308
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------