MEDICARE: PROFORM CLINICS LLC

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

General Provider Information

NPI Number	:	1528607330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFORM CLINICS LLC

Provider Business Mailing Address
First Line	:	1017 LONG PRAIRE ROAD, SUITE 202
Second Line	:
City	:	FLOWER MOUND
State	:	TX
Zip	:	75022-4224
Country	:	US
Telephone Number	:	469-453-2800
Fax Number	:	469-453-3131

Provider Business Practice Location Address
First Line	:	1017 LONG PRAIRE ROAD, SUITE 202
Second Line	:
City	:	FLOWER MOUND
State	:	TX
Zip	:	75022-4224
Country	:	US
Telephone Number	:	469-453-2800
Fax Number	:	469-453-3131

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GORDON R PAYNE
Credential	:	DC
Telephone Number	:	469-453-2800

Provider Enumeration Date	:	12/26/2019
Last Update Date	:	12/26/2019

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Directions to “PROFORM CLINICS LLC ” Practice Location

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