MEDICARE: ANGELO BACK & REHAB, PA

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	4939	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8F5111	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760515373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGELO BACK & REHAB, PA

Provider Business Mailing Address
First Line	:	3950 SUNSET DR
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-5622
Country	:	US
Telephone Number	:	325-949-1600
Fax Number	:	325-944-3754

Provider Business Practice Location Address
First Line	:	3950 SUNSET DR
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-5622
Country	:	US
Telephone Number	:	325-949-1600
Fax Number	:	325-944-3754

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. BRIAN JAY ANDERSON
Credential	:	D.C.
Telephone Number	:	325-949-1600

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	11/29/2010

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Directions to “ANGELO BACK & REHAB, PA ” Practice Location

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