1134534779 NPI number — GREATER TEXAS CLINIC OF CHIROPRACTIC, INC

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 1134534779 NPI number — GREATER TEXAS CLINIC OF CHIROPRACTIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATER TEXAS CLINIC OF CHIROPRACTIC, 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:
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:
1134534779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2117 BLACKJACK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77845-4171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-686-9088
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2205 LONGMIRE DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
COLLEGE STATION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77845-5267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-693-6800
Provider Business Practice Location Address Fax Number:
979-693-6829
Provider Enumeration Date:
06/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MYLAN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
979-693-6800

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  12143 , 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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