Healthcare Provider Details

I. General information

NPI: 1932690237
Provider Name (Legal Business Name): ANNAH GRAVES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5626 FONDREN DR
DALLAS TX
75206-4110
US

IV. Provider business mailing address

5626 FONDREN DR
DALLAS TX
75206-4110
US

V. Phone/Fax

Practice location:
  • Phone: 469-404-5460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number13768
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: