Provider Demographics
NPI:1063497048
Name:LAKE GRANBURY CHIROPRACTIC CTR.
Entity Type:Organization
Organization Name:LAKE GRANBURY CHIROPRACTIC CTR.
Other - Org Name:FAMILY CHIROPRACTIC ASSO., P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONTE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-579-0178
Mailing Address - Street 1:1920 ACTON HWY
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-5988
Mailing Address - Country:US
Mailing Address - Phone:817-579-0178
Mailing Address - Fax:817-573-0441
Practice Address - Street 1:1920 ACTON HWY
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-5988
Practice Address - Country:US
Practice Address - Phone:817-579-0178
Practice Address - Fax:817-573-0441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4673111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXZ00H63E8Medicaid
TXZ00H63E8Medicaid