=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942797766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERB FAMILY WELLNESS SOUTHLAKE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2018
-----------------------------------------------------
Last Update Date | 04/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1845 E SOUTHLAKE BLVD # 140
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-895-0075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 S DENTON TAP RD STE 200
-----------------------------------------------------
City | COPPELL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75019-5050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-556-9595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | KIMBERLY MARIE PINSON-ERB
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 817-895-0075
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 7321
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------