MEDICARE: DAVID BACK CLINIC OF AMERICA INC

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	261QR0400X	Rehabilitation Clinic/Center		TX

General Provider Information

NPI Number	:	1720247844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID BACK CLINIC OF AMERICA INC

Provider Business Mailing Address
First Line	:	3725 COCKRELL AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-4602
Country	:	US
Telephone Number	:	817-921-9981
Fax Number	:	817-921-1407

Provider Business Practice Location Address
First Line	:	3800 HULEN ST
Second Line	:	SUITE 110
City	:	FORT WORTH
State	:	TX
Zip	:	76107-7276
Country	:	US
Telephone Number	:	817-921-9983
Fax Number	:	817-763-9985

Authorized Official
Title or Position	:	VP OPERATIONS
Name	:	MS. CARMA ANDERSON
Credential	:
Telephone Number	:	817-921-9981

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	06/04/2008

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