Healthcare Provider Details

I. General information

NPI: 1255600912
Provider Name (Legal Business Name): CHIRO ONE WELLNESS CENTER OF SOUTH LAKE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2011
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 COMMERCE ST STE F
SOUTHLAKE TX
76092-9100
US

IV. Provider business mailing address

PO BOX 677624
DALLAS TX
75267-7624
US

V. Phone/Fax

Practice location:
  • Phone: 817-865-5520
  • Fax: 817-865-5525
Mailing address:
  • Phone: 630-320-6400
  • Fax: 630-320-6489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: SAM WANG
Title or Position: COO
Credential:
Phone: 630-468-1824