MEDICARE: CHIRO ONE WELLNESS CENTER OF HIGHLAND PARK PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1104194620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIRO ONE WELLNESS CENTER OF HIGHLAND PARK PLLC

Provider Business Mailing Address
First Line	:	PO BOX 677625
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75267
Country	:	US
Telephone Number	:	630-320-6400
Fax Number	:	630-320-6489

Provider Business Practice Location Address
First Line	:	5910 N CENTRAL EXPY
Second Line	:	STE 600
City	:	DALLAS
State	:	TX
Zip	:	75206-5125
Country	:	US
Telephone Number	:	972-619-6450
Fax Number	:	972-619-6451

Authorized Official
Title or Position	:	COO
Name	:	SAM WANG
Credential	:
Telephone Number	:	630-468-1824

Provider Enumeration Date	:	12/12/2011
Last Update Date	:	11/09/2012

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