Provider Demographics
NPI:1205228095
Name:GRAPEVINE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:GRAPEVINE CHIROPRACTIC LLC
Other - Org Name:FAMILY WELLNESS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-310-0998
Mailing Address - Street 1:2011 W NORTHWEST HWY
Mailing Address - Street 2:STE 130
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7857
Mailing Address - Country:US
Mailing Address - Phone:817-310-0998
Mailing Address - Fax:817-310-0994
Practice Address - Street 1:2011 W NORTHWEST HWY
Practice Address - Street 2:STE 130
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7857
Practice Address - Country:US
Practice Address - Phone:817-310-0998
Practice Address - Fax:817-310-0994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12461111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty