1720122807 NPI number — LAKE GRANBURY CHIROPRACTIC CENTER

Table of content: (NPI 1720122807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720122807 NPI number — LAKE GRANBURY CHIROPRACTIC CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE GRANBURY CHIROPRACTIC CENTER
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:
6
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:
1720122807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1920 ACTON HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANBURY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76049-5988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-579-0178
Provider Business Mailing Address Fax Number:
817-573-0441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1920 ACTON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANBURY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76049-5988
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-579-0178
Provider Business Practice Location Address Fax Number:
817-573-0441
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HUDSON
Authorized Official First Name:
MONTE
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
817-579-0178

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4673 , 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)





Copyright © 2007-2025 www.npivalidator.com