Provider Demographics
NPI:1134497316
Name:STICE CHIROPRACTIC & WELLNESS CENTER
Entity type:Organization
Organization Name:STICE CHIROPRACTIC & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:STICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-488-6495
Mailing Address - Street 1:500 N CARROLL AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6410
Mailing Address - Country:US
Mailing Address - Phone:817-488-6495
Mailing Address - Fax:
Practice Address - Street 1:500 N CARROLL AVE
Practice Address - Street 2:STE. 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6410
Practice Address - Country:US
Practice Address - Phone:817-488-6495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11657111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty