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General NPI Number Information
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NPI Number | 1205371556
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Entity Type | Organization
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Legal Business Name | OPTUM HEALTH & SPORT THERAPY
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Dates
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Enumeration Date | 12/22/2016
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Last Update Date | 12/22/2016
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Provider Practice Location Address
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Address Line | 201 TOWN CENTER LN SUITE 1111
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City | KELLER
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State | TX
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Zip | 76248-2158
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Country | US
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Telephone | 817-697-2392
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Fax |
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Provider Business Mailing Address
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Address Line | 201 TOWN CENTER LN SUITE 1111
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City | KELLER
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State | TX
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Zip | 76248-2158
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | BROOKE ANN HALBOTH
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Credential | DC
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Telephone | 817-789-5767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 13362
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License Number State | TX
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