Provider Demographics
NPI:1740468958
Name:SUPERVILLE CHIROPRATIC
Entity type:Organization
Organization Name:SUPERVILLE CHIROPRATIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:SUPERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:713-812-1880
Mailing Address - Street 1:2065 HARLAND DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-1823
Mailing Address - Country:US
Mailing Address - Phone:713-812-1880
Mailing Address - Fax:713-812-1881
Practice Address - Street 1:2065 HARLAND DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-1823
Practice Address - Country:US
Practice Address - Phone:713-812-1880
Practice Address - Fax:713-812-1881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC4527111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T92688Medicare UPIN