Provider Demographics
NPI:1134534779
Name:GREATER TEXAS CLINIC OF CHIROPRACTIC, INC
Entity type:Organization
Organization Name:GREATER TEXAS CLINIC OF CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:MYLAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:979-693-6800
Mailing Address - Street 1:2117 BLACKJACK DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-4171
Mailing Address - Country:US
Mailing Address - Phone:702-686-9088
Mailing Address - Fax:
Practice Address - Street 1:2205 LONGMIRE DR
Practice Address - Street 2:SUITE C
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-5267
Practice Address - Country:US
Practice Address - Phone:979-693-6800
Practice Address - Fax:979-693-6829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12143111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty