Healthcare Provider Details

I. General information

NPI: 1689997264
Provider Name (Legal Business Name): TOTAL BODY REHAB AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 KINWEST PKWY STE: 100
IRVING TX
75063-3135
US

IV. Provider business mailing address

1121 KINWEST PKWY STE: 100
IRVING TX
75063-3135
US

V. Phone/Fax

Practice location:
  • Phone: 972-401-2345
  • Fax: 888-509-1466
Mailing address:
  • Phone: 972-401-2345
  • Fax: 888-509-1466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number11324
License Number StateTX

VIII. Authorized Official

Name: STEWART RY WEAVER
Title or Position: CHIROPRACTOR/ OWNER
Credential: D.C.
Phone: 972-401-2345