Healthcare Provider Details

I. General information

NPI: 1417228768
Provider Name (Legal Business Name): HICKORY CREEK REHAB AND CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 FM 2181 120
HICKORY CREEK TX
75065-7646
US

IV. Provider business mailing address

3630 FM 2181 120
HICKORY CREEK TX
75065-7646
US

V. Phone/Fax

Practice location:
  • Phone: 940-497-7246
  • Fax:
Mailing address:
  • Phone: 940-497-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number11640
License Number StateTX

VIII. Authorized Official

Name: NOEL ERNESTO MAIRENA
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 903-306-9640