Provider Demographics
NPI:1679674600
Name:GRADILLA, JOSE L (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:L
Last Name:GRADILLA
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 1:1120 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3426
Mailing Address - Country:US
Mailing Address - Phone:972-353-4216
Mailing Address - Fax:972-219-7170
Practice Address - Street 1:1120 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3426
Practice Address - Country:US
Practice Address - Phone:972-353-4216
Practice Address - Fax:972-219-7170
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10167111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor