=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891025185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROCK WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2010
-----------------------------------------------------
Last Update Date | 01/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 907 CHAPMAN DR.
-----------------------------------------------------
City | SANGER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-612-3247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2730 OAK TREE DR APT 2506
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75006-2195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WILLIAM CHRISTOPHER PROCK
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 405-612-3247
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 11298
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------