Provider Demographics
NPI:1629520374
Name:MARANATHA GROUP LLC
Entity Type:Organization
Organization Name:MARANATHA GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MILROY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:214-457-4676
Mailing Address - Street 1:705 ROYAL MINISTER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-6390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7777 FOREST LN STE C534
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-6849
Practice Address - Country:US
Practice Address - Phone:972-566-3355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12507111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
368125YXMYMedicare UPIN