MEDICARE: FIRST MOUNTAIN STAR INJURY CLINIC

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	4847	TX
2	111N00000X	Chiropractor	9245	TX

General Provider Information

NPI Number	:	1275716425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST MOUNTAIN STAR INJURY CLINIC

Provider Business Mailing Address
First Line	:	5630 GATEWAY BLVD E
Second Line	:	STE. 5-E
City	:	EL PASO
State	:	TX
Zip	:	79905-1748
Country	:	US
Telephone Number	:	915-781-7827
Fax Number	:	915-781-0884

Provider Business Practice Location Address
First Line	:	5630 GATEWAY BLVD E
Second Line	:	STE. 5-E
City	:	EL PASO
State	:	TX
Zip	:	79905-1748
Country	:	US
Telephone Number	:	915-781-7827
Fax Number	:	915-781-0884

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ART ARCHULETA JR.
Credential	:
Telephone Number	:	915-781-7827

Provider Enumeration Date	:	12/11/2007
Last Update Date	:	12/11/2007

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