1154552834 NPI number — PRO-ADJUSTER CHIROPRACTIC CLINIC, INC.

Table of content: (NPI 1154552834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154552834 NPI number — PRO-ADJUSTER CHIROPRACTIC CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRO-ADJUSTER CHIROPRACTIC CLINIC, INC.
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:
IDEAL HEALTH OF DALLAS
Provider Other Organization Name Type Code:
4
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:
1154552834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 E BELT LINE RD
Provider Second Line Business Mailing Address:
STE. G
Provider Business Mailing Address City Name:
CEDAR HILL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75104-2274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-291-1992
Provider Business Mailing Address Fax Number:
972-291-1163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 E BELT LINE RD
Provider Second Line Business Practice Location Address:
STE. G
Provider Business Practice Location Address City Name:
CEDAR HILL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75104-2274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-291-1992
Provider Business Practice Location Address Fax Number:
972-291-1163
Provider Enumeration Date:
07/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ANSELL
Authorized Official First Name:
LESA
Authorized Official Middle Name:
GILLEZEAU
Authorized Official Title or Position:
OWNER/CHIROPRACTOR
Authorized Official Telephone Number:
972-291-1992

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  8020 , 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)





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