Provider Demographics
NPI:1932361755
Name:PRO HEALTH CHIROPRACTIC
Entity Type:Organization
Organization Name:PRO HEALTH CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GODSEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-509-9990
Mailing Address - Street 1:4505 TROUP HWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-2350
Mailing Address - Country:US
Mailing Address - Phone:903-509-9990
Mailing Address - Fax:903-509-3390
Practice Address - Street 1:4505 TROUP HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2350
Practice Address - Country:US
Practice Address - Phone:903-509-9990
Practice Address - Fax:903-509-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9796111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXV02343Medicare UPIN