MEDICARE: CHIROPRACTIC OF SAN ANGELO, PC

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	111NS0005X	Sports Physician Chiropractor	5195	TX

General Provider Information

NPI Number	:	1174680607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIROPRACTIC OF SAN ANGELO, PC

Provider Business Mailing Address
First Line	:	3184 EXECUTIVE DR
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-6802
Country	:	US
Telephone Number	:	325-949-8688
Fax Number	:	325-944-2235

Provider Business Practice Location Address
First Line	:	3184 EXECUTIVE DR
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-6802
Country	:	US
Telephone Number	:	325-949-8688
Fax Number	:	325-944-2235

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DARCI JILL STOTTS
Credential	:	D.C.
Telephone Number	:	325-949-8688

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/21/2022

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