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General NPI Number Information
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NPI Number | 1558732123
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Entity Type | Organization
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Legal Business Name | GREENHEAD DIAGNOSTICS, LLC
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Dates
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Enumeration Date | 10/08/2015
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Last Update Date | 10/08/2015
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Provider Practice Location Address
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Address Line | 637 MERLOT CT
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City | FAIRVIEW
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State | TX
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Zip | 75069-1521
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Country | US
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Telephone | 214-383-9622
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Fax |
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Provider Business Mailing Address
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Address Line | 3245 MAIN ST SUITE 235-157
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City | FRISCO
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State | TX
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Zip | 75034-4411
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Country | US
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Telephone | 214-383-9622
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MACKIE DAWAYNE GOURLEY JR.
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Credential | DC
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Telephone | 214-680-9146
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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 | 12359
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License Number State | TX
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