Provider Demographics
NPI:1134326739
Name:KILLEEN INJURY CLINIC, INC.
Entity Type:Organization
Organization Name:KILLEEN INJURY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NAT
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-688-6628
Mailing Address - Street 1:5931 DESCO DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225
Mailing Address - Country:US
Mailing Address - Phone:214-692-6666
Mailing Address - Fax:214-692-6670
Practice Address - Street 1:100 E CENTRAL TEXAS EXPY
Practice Address - Street 2:SUITE 100
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541-8525
Practice Address - Country:US
Practice Address - Phone:254-501-3555
Practice Address - Fax:254-501-3554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14136101YP2500X
TXJ1957208D00000X
TX1030278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty