Provider Demographics
NPI:1639529811
Name:HEALTHSOURCE OF COPPERFIELD, LLC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF COPPERFIELD, LLC
Other - Org Name:HEALTHSOURCE CHIROPRACTIC AND PROGRESSIVE REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:214-519-1755
Mailing Address - Street 1:8925 HIGHWAY 6 N
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-2457
Mailing Address - Country:US
Mailing Address - Phone:281-858-4446
Mailing Address - Fax:
Practice Address - Street 1:8711 HIGHWAY 6 N STE 210
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-2272
Practice Address - Country:US
Practice Address - Phone:281-858-4446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-17
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11457111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX410526ZK5AOtherMEDICARE PTAN