MEDICARE: BROWN SPINE & SPORTS CHIROPRACTIC 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	111NS0005X	Sports Physician Chiropractor	10586	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TXB130970	OTHER	TX	PTAN

General Provider Information

NPI Number	:	1518413392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROWN SPINE & SPORTS CHIROPRACTIC CLINIC

Provider Business Mailing Address
First Line	:	6040 CAMP BOWIE BLVD STE 2
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5602
Country	:	US
Telephone Number	:	817-763-8301
Fax Number	:	817-764-6488

Provider Business Practice Location Address
First Line	:	6040 CAMP BOWIE BLVD STE 2
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5602
Country	:	US
Telephone Number	:	817-763-8301
Fax Number	:	817-764-6488

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DANIEL L BROWN
Credential	:	D.C.
Telephone Number	:	817-763-8301

Provider Enumeration Date	:	08/31/2016
Last Update Date	:	08/31/2016

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