Healthcare Provider Details

I. General information

NPI: 1487652731
Provider Name (Legal Business Name): SOI N SY DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1833 W MAIN ST
GUN BARREL CITY TX
75156-4401
US

IV. Provider business mailing address

1833 W MAIN ST
GUN BARREL CITY TX
75156-4401
US

V. Phone/Fax

Practice location:
  • Phone: 903-887-6155
  • Fax: 903-887-6755
Mailing address:
  • Phone: 903-887-6155
  • Fax: 903-887-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC8867
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: