Healthcare Provider Details

I. General information

NPI: 1699147090
Provider Name (Legal Business Name): TESTIMONIAL SPINE & FITNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2015
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6363 RICHMOND AVE STE 260
HOUSTON TX
77057-5950
US

IV. Provider business mailing address

6122 GLADEWELL DR
HOUSTON TX
77072-1502
US

V. Phone/Fax

Practice location:
  • Phone: 832-580-9743
  • Fax: 832-201-0797
Mailing address:
  • Phone: 832-580-9743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number13068
License Number StateTX

VIII. Authorized Official

Name: DR. ANTHONY JULIO BRANKER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 832-580-9743