=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346894466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODIED CHIROPRACTIC CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2019
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2616 S LOOP W STE 430
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-802-2984
-----------------------------------------------------
Fax | 346-571-2903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2616 S LOOP W STE 430
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-802-2984
-----------------------------------------------------
Fax | 346-571-2903
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DONNA LUCILLE KELLY
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 346-802-2984
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------