Provider Demographics
NPI:1104850429
Name:CARROLLTON KINESIOLOGY & CHIROPRACTIC HEALTH CENTER
Entity Type:Organization
Organization Name:CARROLLTON KINESIOLOGY & CHIROPRACTIC HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:JAILLET
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-395-9795
Mailing Address - Street 1:3610 N JOSEY LN STE 130
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-3143
Mailing Address - Country:US
Mailing Address - Phone:972-395-9795
Mailing Address - Fax:
Practice Address - Street 1:3610 N JOSEY LN STE 130
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-3143
Practice Address - Country:US
Practice Address - Phone:972-395-9795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6689111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00485XMedicare ID - Type Unspecified