MEDICARE: DR. BARON TYRONE NICKLEBERRY D.C.

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	9283	TX
2	111NR0400X	Rehabilitation Chiropractor	9283	TX
3	111NS0005X	Sports Physician Chiropractor	9283	TX

General Provider Information

NPI Number	:	1205058310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BARON TYRONE NICKLEBERRY D.C.

Provider Business Mailing Address
First Line	:	7410 BLANCO RD STE 400
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-4363
Country	:	US
Telephone Number	:	800-404-6050
Fax Number	:	210-477-4956

Provider Business Practice Location Address
First Line	:	7410 BLANCO RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-4363
Country	:	US
Telephone Number	:	800-404-6050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	08/22/2008

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