Provider Demographics
NPI:1619687266
Name:AMBROSE, RONNIE KOVA (DC)
Entity Type:Individual
Prefix:DR
First Name:RONNIE
Middle Name:KOVA
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S JACKSON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-3938
Mailing Address - Country:US
Mailing Address - Phone:214-284-1293
Mailing Address - Fax:
Practice Address - Street 1:102 S JACKSON AVE STE A
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-3938
Practice Address - Country:US
Practice Address - Phone:214-284-1293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15361111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor