MEDICARE: JOHN E PETTY DC PC

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	2365	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821121872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN E PETTY DC PC

Provider Business Mailing Address
First Line	:	452 FOREST SQ
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75605-4401
Country	:	US
Telephone Number	:	903-757-3400
Fax Number	:	903-753-9663

Provider Business Practice Location Address
First Line	:	452 FOREST SQ
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75605-4401
Country	:	US
Telephone Number	:	903-757-3400
Fax Number	:	903-753-9663

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN E PETTY
Credential	:	D.C.
Telephone Number	:	903-757-3400

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	09/21/2011

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