MEDICARE: DR. MICHAEL A BOOTH DC, DACBN, CCN

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	6964	TX
2	111NN1001X	Nutrition Chiropractor	6964	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	608109	OTHER	TX	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1518960863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL A BOOTH DC, DACBN, CCN

Provider Business Mailing Address
First Line	:	10311 W HIDDEN LAKE LN
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77469-7708
Country	:	US
Telephone Number	:	281-342-5941
Fax Number	:	281-342-5953

Provider Business Practice Location Address
First Line	:	5529 FM 359 RD
Second Line	:	STE A
City	:	RICHMOND
State	:	TX
Zip	:	77469-9659
Country	:	US
Telephone Number	:	281-342-5941
Fax Number	:	281-342-5953

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

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	03/27/2013

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