Provider Demographics
NPI:1558696971
Name:MOUNARATH, VANDARA (DC)
Entity Type:Individual
Prefix:DR
First Name:VANDARA
Middle Name:
Last Name:MOUNARATH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 W WALL ST
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-5151
Mailing Address - Country:US
Mailing Address - Phone:817-458-1025
Mailing Address - Fax:888-848-3798
Practice Address - Street 1:1011 W WALL ST
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5151
Practice Address - Country:US
Practice Address - Phone:817-458-1025
Practice Address - Fax:888-848-3798
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-03
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11215111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB141410Medicare PIN