Provider Demographics
NPI:1558732123
Name:GREENHEAD DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:GREENHEAD DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MACKIE
Authorized Official - Middle Name:DAWAYNE
Authorized Official - Last Name:GOURLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:214-680-9146
Mailing Address - Street 1:3245 MAIN ST
Mailing Address - Street 2:SUITE 235-157
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-4411
Mailing Address - Country:US
Mailing Address - Phone:214-383-9622
Mailing Address - Fax:
Practice Address - Street 1:637 MERLOT CT
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:TX
Practice Address - Zip Code:75069-1521
Practice Address - Country:US
Practice Address - Phone:214-383-9622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12359111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty