MEDICARE: KEYSTONE CHIROPRACTIC

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	F006430	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0010LC	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1932245750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEYSTONE CHIROPRACTIC

Provider Business Mailing Address
First Line	:	6101 WINDCOM CT
Second Line	:	STE 300
City	:	PLANO
State	:	TX
Zip	:	75093-7817
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6101 WINDCOM CT
Second Line	:	STE 300
City	:	PLANO
State	:	TX
Zip	:	75093-7817
Country	:	US
Telephone Number	:	972-378-9991
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NICHOLAS J COLEMAN
Credential	:	D.C.
Telephone Number	:	972-378-9991

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	08/22/2020

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1316063993 — JOHN ALLEN VAN WAGONER, MD, PA
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Directions to “KEYSTONE CHIROPRACTIC ” Practice Location

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