MEDICARE: STACIA GAMMAGE DC,AT

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	2255A2300X	Athletic Trainer	AT586	AR
2	111N00000X	Chiropractor	15708	TX

General Provider Information

NPI Number	:	1841608536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIA GAMMAGE DC,AT

Provider Business Mailing Address
First Line	:	5521 BELLAIRE DR S STE 110
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5855
Country	:	US
Telephone Number	:	817-926-9642
Fax Number	:	817-926-1865

Provider Business Practice Location Address
First Line	:	5521 BELLAIRE DR S STE 110
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5855
Country	:	US
Telephone Number	:	817-926-9642
Fax Number	:	817-926-1865

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

Provider Enumeration Date	:	07/26/2014
Last Update Date	:	08/02/2023

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