MEDICARE: JK7 PROMISLAND, 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	4994	TX

General Provider Information

NPI Number	:	1861777526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JK7 PROMISLAND, INC.

Provider Business Mailing Address
First Line	:	4828 S BROADWAY AVE # 142
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-1312
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6775 OLD JACKSONVILLE HWY # 2
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-0508
Country	:	US
Telephone Number	:	903-509-8000
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JEFFREY LEON SHIRLEY
Credential	:
Telephone Number	:	903-509-8000

Provider Enumeration Date	:	10/13/2011
Last Update Date	:	10/13/2011

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