Healthcare Provider Details

I. General information

NPI: 1396883724
Provider Name (Legal Business Name): AGRITELLEY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6060 DILBECK LN
DALLAS TX
75240-5351
US

IV. Provider business mailing address

6060 DILBECK LN
DALLAS TX
75240-5351
US

V. Phone/Fax

Practice location:
  • Phone: 469-916-1592
  • Fax: 972-458-6829
Mailing address:
  • Phone: 469-916-1592
  • Fax: 972-458-6829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number10258
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1153020
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number9065
License Number StateTX

VIII. Authorized Official

Name: DR. CAMILLE CATHERINE EBERLE
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 469-916-1592