Provider Demographics
NPI:1609011840
Name:EAGLE CHIROPRACTIC WELLNESS CENTER, PC
Entity Type:Organization
Organization Name:EAGLE CHIROPRACTIC WELLNESS CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EAGLE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:KNIFE CHIEF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:580-272-4169
Mailing Address - Street 1:4708 W PLANO PKWY
Mailing Address - Street 2:#300
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5333
Mailing Address - Country:US
Mailing Address - Phone:972-265-8103
Mailing Address - Fax:972-265-8110
Practice Address - Street 1:4708 W PLANO PKWY
Practice Address - Street 2:#300
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5333
Practice Address - Country:US
Practice Address - Phone:972-265-8103
Practice Address - Fax:972-265-8110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10775111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXSB2037Medicare PIN