Provider Demographics
NPI:1700293453
Name:LAKE TEXOMA CHIROPRACTIC
Entity Type:Organization
Organization Name:LAKE TEXOMA CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BEIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-327-9166
Mailing Address - Street 1:81750 N STATE HWY 289 STE 102
Mailing Address - Street 2:
Mailing Address - City:POTTSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75076-4966
Mailing Address - Country:US
Mailing Address - Phone:330-482-9350
Mailing Address - Fax:330-482-2336
Practice Address - Street 1:81750 N STATE HWY 289 STE 102
Practice Address - Street 2:
Practice Address - City:POTTSBORO
Practice Address - State:TX
Practice Address - Zip Code:75076
Practice Address - Country:US
Practice Address - Phone:903-327-9166
Practice Address - Fax:888-886-8139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-15
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009315111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001676219OtherHIGHMARK
TX3413536-01Medicaid
PADE8220OtherRR MEDICARE
PA086580PQUMedicare PIN