Healthcare Provider Details

I. General information

NPI: 1275526873
Provider Name (Legal Business Name): LONNY R MCKINZIE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 10/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 OLD BULLARD RD SUITE 350
TYLER TX
75701-8650
US

IV. Provider business mailing address

3600 OLD BULLARD RD. SUITE 350
TYLER TX
75701-8662
US

V. Phone/Fax

Practice location:
  • Phone: 903-531-2243
  • Fax: 903-787-8847
Mailing address:
  • Phone: 903-531-2243
  • Fax: 903-787-8847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC5469
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: