Provider Demographics
NPI:1598122939
Name:ABC WELLNESS CENTER OF IRVING
Entity Type:Organization
Organization Name:ABC WELLNESS CENTER OF IRVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:DUSTIN
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:972-699-3696
Mailing Address - Street 1:1425 W PIONEER DR
Mailing Address - Street 2:SUITE 112 A
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-7146
Mailing Address - Country:US
Mailing Address - Phone:972-699-3696
Mailing Address - Fax:469-828-1644
Practice Address - Street 1:1425 W PIONEER DR
Practice Address - Street 2:SUITE 112 A
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-7146
Practice Address - Country:US
Practice Address - Phone:972-699-3696
Practice Address - Fax:469-828-1644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11260111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty