MEDICARE: EMERALD CHIROPRACTIC CENTER P.C.

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	111NR0400X	Rehabilitation Chiropractor	4141	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	83V082 / OOL33G	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1710162961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD CHIROPRACTIC CENTER P.C.

Provider Business Mailing Address
First Line	:	PO BOX 1688
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77574-1688
Country	:	US
Telephone Number	:	281-332-9631
Fax Number	:	281-332-8192

Provider Business Practice Location Address
First Line	:	2047 W MAIN ST
Second Line	:	SUITE A8
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-3579
Country	:	US
Telephone Number	:	281-332-9631
Fax Number	:	281-332-8192

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN PAUL HODGES JR.
Credential	:	D.C.
Telephone Number	:	281-332-9631

Provider Enumeration Date	:	01/07/2008
Last Update Date	:	01/07/2008

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