MEDICARE: DYNAMIC SPINE AND PERFORMANCE CENTER, 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	:	1649787631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC SPINE AND PERFORMANCE CENTER, LLC

Provider Business Mailing Address
First Line	:	11511 KATY FWY
Second Line	:	SUITE 418
City	:	HOUSTON
State	:	TX
Zip	:	77079-1903
Country	:	US
Telephone Number	:	713-955-7972
Fax Number	:	713-588-8445

Provider Business Practice Location Address
First Line	:	11511 KATY FWY
Second Line	:	SUITE 418
City	:	HOUSTON
State	:	TX
Zip	:	77079-1903
Country	:	US
Telephone Number	:	713-955-7972
Fax Number	:	713-588-8445

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STEPHEN TYLER FORD
Credential	:	DC
Telephone Number	:	281-770-3613

Provider Enumeration Date	:	12/29/2017
Last Update Date	:	12/29/2017

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