Healthcare Provider Details

I. General information

NPI: 1598910648
Provider Name (Legal Business Name): GLEN HAYWOOD DC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N GUN BARREL LN
GUN BARREL CITY TX
75156-3724
US

IV. Provider business mailing address

PO BOX 242
MABANK TX
75147-0242
US

V. Phone/Fax

Practice location:
  • Phone: 903-887-1417
  • Fax:
Mailing address:
  • Phone: 903-887-1417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2459
License Number StateTX

VIII. Authorized Official

Name: GLEN HAYWOOD
Title or Position: OWNER
Credential: DC PC
Phone: 903-887-1417