Provider Demographics
NPI:1588808778
Name:HEALTHSOURCE OF WEST CHAMBERS CHIROPRACTIC & PROGRESSIVE REHAB
Entity Type:Organization
Organization Name:HEALTHSOURCE OF WEST CHAMBERS CHIROPRACTIC & PROGRESSIVE REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:281-383-0004
Mailing Address - Street 1:4520 FM 565 SOUTH
Mailing Address - Street 2:
Mailing Address - City:COVE
Mailing Address - State:TX
Mailing Address - Zip Code:77523-4884
Mailing Address - Country:US
Mailing Address - Phone:281-383-0004
Mailing Address - Fax:281-383-0007
Practice Address - Street 1:4520 FM 565 SOUTH
Practice Address - Street 2:
Practice Address - City:COVE
Practice Address - State:TX
Practice Address - Zip Code:77523-4884
Practice Address - Country:US
Practice Address - Phone:281-383-0004
Practice Address - Fax:281-383-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5323111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX609203Medicare PIN