Provider Demographics
NPI:1699028084
Name:HEALTHSOURCE OF FRISCO LLC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF FRISCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:M. BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC PA
Authorized Official - Phone:817-291-1816
Mailing Address - Street 1:7010 PRESTON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-5869
Mailing Address - Country:US
Mailing Address - Phone:469-633-1155
Mailing Address - Fax:
Practice Address - Street 1:7010 PRESTON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-5869
Practice Address - Country:US
Practice Address - Phone:469-633-1155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty