Provider Demographics
NPI:1518979509
Name:SOUTHERLAND, DALE ALAN (DC)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:ALAN
Last Name:SOUTHERLAND
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3206 MANVEL RD
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7580
Mailing Address - Country:US
Mailing Address - Phone:281-997-8788
Mailing Address - Fax:281-997-8797
Practice Address - Street 1:3206 MANVEL RD
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7580
Practice Address - Country:US
Practice Address - Phone:281-997-8788
Practice Address - Fax:281-997-8797
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6914111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX605368OtherBCBS
TX001896201Medicaid
TX605368OtherBCBS
TX001896201Medicaid