Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 5714 | TX |
NPI | 1003952847 |
---|---|
Provider Name | Dr. Jack L Mikeworth |
First Address | Arlington, TX 76015-3228 |
Second Address | Fort Worth, TX 76104-6066 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2007 |
Last Update Date | 08/07/2007 |