Healthcare Provider Details

I. General information

NPI: 1316191984
Provider Name (Legal Business Name): STRUCTURE CHIROPRACTIC AND PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4508 LEGACY DR SUITE 200
PLANO TX
75024-2183
US

IV. Provider business mailing address

4508 LEGACY DR SUITE 200
PLANO TX
75024-2183
US

V. Phone/Fax

Practice location:
  • Phone: 214-377-4833
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number11011
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number11018
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1152378
License Number StateTX

VIII. Authorized Official

Name: HOMERO CAVAZOS
Title or Position: OWNER
Credential:
Phone: 214-914-5684