Healthcare Provider Details

I. General information

NPI: 1114719226
Provider Name (Legal Business Name): SAMUEL ADAM BLANKENBURG DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E ROYAL LN STE 125
IRVING TX
75039-4215
US

IV. Provider business mailing address

100 E ROYAL LN STE 125
IRVING TX
75039-4215
US

V. Phone/Fax

Practice location:
  • Phone: 214-920-9111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number16475
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: