=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114369733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAIN-BODY CONNECTION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2013
-----------------------------------------------------
Last Update Date | 11/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 CASIE CT
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76207-7612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-230-5220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 DALLAS DR STE 112
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76205-5121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-808-0622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. TWILA DE VON HENDERSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 940-230-5220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 12394
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------