1942791116 NPI number — ILLUMIN8 MCKINNEY CHIROPRACTIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942791116 NPI number — ILLUMIN8 MCKINNEY CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLUMIN8 MCKINNEY CHIROPRACTIC
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:
1942791116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
833 SILVER AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87102-3020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-433-4646
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 S TENNESSEE ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCKINNEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75069-4354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-309-3410
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
PHELPS
Authorized Official First Name:
SHELBY
Authorized Official Middle Name:
PAIGE
Authorized Official Title or Position:
DC
Authorized Official Telephone Number:
469-309-3410

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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