Provider Demographics
NPI:1205371556
Name:OPTUM HEALTH & SPORT THERAPY
Entity type:Organization
Organization Name:OPTUM HEALTH & SPORT THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HALBOTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-789-5767
Mailing Address - Street 1:201 TOWN CENTER LN
Mailing Address - Street 2:SUITE 1111
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 TOWN CENTER LN
Practice Address - Street 2:SUITE 1111
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2158
Practice Address - Country:US
Practice Address - Phone:817-697-2392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13362111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty