Provider Demographics
NPI:1114023934
Name:COFFEE, MARENTHA S (DC)
Entity Type:Individual
Prefix:DR
First Name:MARENTHA
Middle Name:S
Last Name:COFFEE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14330 MIDWAY RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-3522
Mailing Address - Country:US
Mailing Address - Phone:469-547-1173
Mailing Address - Fax:469-629-5007
Practice Address - Street 1:14330 MIDWAY RD
Practice Address - Street 2:SUITE 116
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-3522
Practice Address - Country:US
Practice Address - Phone:469-547-1173
Practice Address - Fax:469-629-5007
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9622111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8P1441OtherBCBS
TXV04810Medicare UPIN