Provider Demographics
NPI:1437144631
Name:CHIROPRACTIC CARE CENTER OF SOUTHLAKE, P.C.
Entity Type:Organization
Organization Name:CHIROPRACTIC CARE CENTER OF SOUTHLAKE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TYCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HERGERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-416-6116
Mailing Address - Street 1:1500 W SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5950
Mailing Address - Country:US
Mailing Address - Phone:817-416-6116
Mailing Address - Fax:817-410-9411
Practice Address - Street 1:1500 W SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5950
Practice Address - Country:US
Practice Address - Phone:817-416-6116
Practice Address - Fax:817-410-9411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000030ZMedicare ID - Type Unspecified