1013035682 NPI number — MISSION CHIROPRACTIC AND INJURY CLINIC, P.A.

Table of content: (NPI 1013035682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013035682 NPI number — MISSION CHIROPRACTIC AND INJURY CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSION CHIROPRACTIC AND INJURY CLINIC, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013035682
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7330 SAN PEDRO AVE STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78216-6236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-342-4000
Provider Business Mailing Address Fax Number:
210-342-4181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7330 SAN PEDRO AVE STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78216-6236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-342-4000
Provider Business Practice Location Address Fax Number:
210-342-4181
Provider Enumeration Date:
03/26/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRIMM
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
210-342-4000

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC6997 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2664613 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8F4900 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: DC6997 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".