Provider Demographics
NPI:1295065118
Name:LOVERS LANE WELLNESS CENTER LLC
Entity type:Organization
Organization Name:LOVERS LANE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TISKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-766-0589
Mailing Address - Street 1:3844 MARTHA LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-6126
Mailing Address - Country:US
Mailing Address - Phone:214-351-3904
Mailing Address - Fax:214-351-2072
Practice Address - Street 1:12800 PRESTON RD.
Practice Address - Street 2:STE. 201
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230
Practice Address - Country:US
Practice Address - Phone:214-351-2299
Practice Address - Fax:214-351-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10106111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty