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General NPI Number Information
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NPI Number | 1275040115
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Entity Type | Organization
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Legal Business Name | RENEWED EAGLE CHIROPRACTIC
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Dates
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Enumeration Date | 12/31/2017
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Last Update Date | 12/31/2017
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Provider Practice Location Address
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Address Line | 3500 WILLIAM D TATE AVE STE 175
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City | GRAPEVINE
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State | TX
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Zip | 76051-8749
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Country | US
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Telephone | 817-421-4775
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Fax |
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Provider Business Mailing Address
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Address Line | 700 OAKWOOD AVE
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City | HURST
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State | TX
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Zip | 76053-5511
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Country | US
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Telephone | 817-688-8999
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Fax |
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Authorized Official
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Title or Position | BUSINESS OWNER/CHIROPRACTOR
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Name | NATALIE MARIE MOORE
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Credential | D.C.
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Telephone | 817-688-8999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 13549
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License Number State | TX
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