Healthcare Provider Details

I. General information

NPI: 1548556624
Provider Name (Legal Business Name): 180 WELLNESS, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 W SOUTHLAKE BLVD STE 100
SOUTHLAKE TX
76092-6188
US

IV. Provider business mailing address

321 W. SOUTHLAKE BLVD STE 100
SOUTHLAKE TX
76092-6188
US

V. Phone/Fax

Practice location:
  • Phone: 817-337-5199
  • Fax:
Mailing address:
  • Phone: 817-337-5199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6927
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6741
License Number StateTX

VIII. Authorized Official

Name: MR. DAVID WADE PARKHILL
Title or Position: DOCTOR
Credential: D.C.
Phone: 817-337-5199