Provider Demographics
NPI:1528607330
Name:PROFORM CLINICS LLC
Entity Type:Organization
Organization Name:PROFORM CLINICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:R
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:469-453-2800
Mailing Address - Street 1:1017 LONG PRAIRE ROAD, SUITE 202
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-4224
Mailing Address - Country:US
Mailing Address - Phone:469-453-2800
Mailing Address - Fax:469-453-3131
Practice Address - Street 1:1017 LONG PRAIRE ROAD, SUITE 202
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-4224
Practice Address - Country:US
Practice Address - Phone:469-453-2800
Practice Address - Fax:469-453-3131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty