MEDICARE: DR. GARY W SANDERS D.C., F.A.S.A

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	4758	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TXB129427	OTHER	TX	MEDICARE PTAN

General Provider Information

NPI Number	:	1770623449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY W SANDERS D.C., F.A.S.A

Provider Business Mailing Address
First Line	:	4712 BOAT CLUB RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-2002
Country	:	US
Telephone Number	:	817-237-2930
Fax Number	:	817-237-4143

Provider Business Practice Location Address
First Line	:	4712 BOAT CLUB RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-2002
Country	:	US
Telephone Number	:	817-237-2930
Fax Number	:	817-237-4143

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	11/14/2016

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