Provider Demographics
NPI:1902999113
Name:COLEGROVE, JOHNNY ALLEN (DC)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:ALLEN
Last Name:COLEGROVE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 N PACIFIC
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:TX
Mailing Address - Zip Code:75773
Mailing Address - Country:US
Mailing Address - Phone:903-569-6261
Mailing Address - Fax:903-569-1792
Practice Address - Street 1:1044 N PACIFIC
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773
Practice Address - Country:US
Practice Address - Phone:903-569-6261
Practice Address - Fax:903-569-1792
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4217111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5676121OtherAETNA
TX001341901Medicaid
TX601744OtherBCBS
TX601744Medicare ID - Type Unspecified
TX001341901Medicaid