Provider Demographics
NPI:1770360257
Name:PANTEGO INJURY CLINIC INC
Entity type:Organization
Organization Name:PANTEGO INJURY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-576-3136
Mailing Address - Street 1:PO BOX 195884
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-8615
Mailing Address - Country:US
Mailing Address - Phone:469-576-3136
Mailing Address - Fax:
Practice Address - Street 1:3216 W PARK ROW DR STE B
Practice Address - Street 2:
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-3136
Practice Address - Country:US
Practice Address - Phone:682-800-2185
Practice Address - Fax:469-533-0307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty