MEDICARE: PANTEGO INJURY CLINIC 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	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1770360257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PANTEGO INJURY CLINIC INC

Provider Business Mailing Address
First Line	:	PO BOX 195884
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-8615
Country	:	US
Telephone Number	:	469-576-3136
Fax Number	:

Provider Business Practice Location Address
First Line	:	3216 W PARK ROW DR STE B
Second Line	:
City	:	PANTEGO
State	:	TX
Zip	:	76013-3136
Country	:	US
Telephone Number	:	682-800-2185
Fax Number	:	469-533-0307

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DAVID LONG
Credential	:
Telephone Number	:	469-576-3136

Provider Enumeration Date	:	09/11/2023
Last Update Date	:	09/11/2023

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