Provider Demographics
NPI:1558898494
Name:GOURLEY, MACKIE DAWAYNE JR (CHIROPRACTOR)
Entity Type:Individual
Prefix:MR
First Name:MACKIE
Middle Name:DAWAYNE
Last Name:GOURLEY
Suffix:JR
Gender:M
Credentials:CHIROPRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N WATTERS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5344
Mailing Address - Country:US
Mailing Address - Phone:469-519-1282
Mailing Address - Fax:972-696-0210
Practice Address - Street 1:190 E STACY RD STE 306-397
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-8734
Practice Address - Country:US
Practice Address - Phone:469-519-1282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0011681111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty