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General NPI Number Information
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NPI Number | 1720122807
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Entity Type | Organization
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Legal Business Name | LAKE GRANBURY CHIROPRACTIC CENTER
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 01/29/2008
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Provider Practice Location Address
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Address Line | 1920 ACTON HWY
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City | GRANBURY
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State | TX
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Zip | 76049-5988
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Country | US
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Telephone | 817-579-0178
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Fax | 817-573-0441
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Provider Business Mailing Address
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Address Line | 1920 ACTON HWY
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City | GRANBURY
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State | TX
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Zip | 76049-5988
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Country | US
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Telephone | 817-579-0178
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Fax | 817-573-0441
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. MONTE WAYNE HUDSON
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Credential | D.C.
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Telephone | 817-579-0178
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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 | 4673
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License Number State | TX
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