Provider Demographics
NPI:1063743755
Name:SOUTHLAKE CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:SOUTHLAKE CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-488-8837
Mailing Address - Street 1:170 PLAYERS CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6947
Mailing Address - Country:US
Mailing Address - Phone:817-488-8837
Mailing Address - Fax:817-488-8927
Practice Address - Street 1:170 PLAYERS CIR STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6947
Practice Address - Country:US
Practice Address - Phone:817-488-8837
Practice Address - Fax:817-488-8927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8031111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty