Provider Demographics
NPI:1245424050
Name:LAGUNA MADRE CHIROPRACTIC, P.A.
Entity Type:Organization
Organization Name:LAGUNA MADRE CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FLAIG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:956-943-9943
Mailing Address - Street 1:402 S GARCIA ST
Mailing Address - Street 2:
Mailing Address - City:PORT ISABEL
Mailing Address - State:TX
Mailing Address - Zip Code:78578-4103
Mailing Address - Country:US
Mailing Address - Phone:956-943-9943
Mailing Address - Fax:
Practice Address - Street 1:402 S GARCIA ST
Practice Address - Street 2:
Practice Address - City:PORT ISABEL
Practice Address - State:TX
Practice Address - Zip Code:78578-4103
Practice Address - Country:US
Practice Address - Phone:956-943-9943
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8502111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0091JKOtherBC / BS GROUP #
TX0049OUMedicare PIN