Provider Demographics
NPI:1730308198
Name:HEBERT SOUTHLAKE CHIROPRACTIC
Entity Type:Organization
Organization Name:HEBERT SOUTHLAKE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-488-8837
Mailing Address - Street 1:170 PLAYERS CIRCLE
Mailing Address - Street 2:#100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-488-8837
Mailing Address - Fax:817-488-8927
Practice Address - Street 1:170 PLAYERS CIRCLE
Practice Address - Street 2:#100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6943
Practice Address - Country:US
Practice Address - Phone:817-488-8837
Practice Address - Fax:817-488-8837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4244111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111N00000XOtherTAXONOMIES
TX4632699OtherAETNA
TX0040PDOtherBLUECROSS BLUESHIELD
TX0040PDOtherBLUECROSS BLUESHIELD