Provider Demographics
NPI:1760759633
Name:HEALTHSOURCE OF HIGHLAND VILLAGE LLC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF HIGHLAND VILLAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFREITAS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-316-4150
Mailing Address - Street 1:200 MARKET PL
Mailing Address - Street 2:STE 225
Mailing Address - City:HIGHLAND VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-3272
Mailing Address - Country:US
Mailing Address - Phone:972-316-4150
Mailing Address - Fax:972-316-4155
Practice Address - Street 1:200 MARKET PL
Practice Address - Street 2:STE 225
Practice Address - City:HIGHLAND VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75077-3272
Practice Address - Country:US
Practice Address - Phone:972-316-4150
Practice Address - Fax:972-316-4155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty