Provider Demographics
NPI:1902819121
Name:VANGUARD MEDICAL ALLIANCE
Entity Type:Organization
Organization Name:VANGUARD MEDICAL ALLIANCE
Other - Org Name:COLLEYVILLE WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-485-2300
Mailing Address - Street 1:PO BOX 1200
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-1200
Mailing Address - Country:US
Mailing Address - Phone:817-485-2300
Mailing Address - Fax:817-485-2356
Practice Address - Street 1:16 VILLAGE LN
Practice Address - Street 2:SUITE 220
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-2946
Practice Address - Country:US
Practice Address - Phone:817-485-2300
Practice Address - Fax:817-485-2356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC6579111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty