Provider Demographics
NPI:1982734851
Name:A CHIROPRACTOR ON HWY 155, INC
Entity type:Organization
Organization Name:A CHIROPRACTOR ON HWY 155, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:COLEMAN
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-729-3772
Mailing Address - Street 1:PO BOX 950
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75802-0950
Mailing Address - Country:US
Mailing Address - Phone:903-729-3772
Mailing Address - Fax:903-723-0920
Practice Address - Street 1:2114 STATE HIGHWAY 155
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75803-8606
Practice Address - Country:US
Practice Address - Phone:903-729-3772
Practice Address - Fax:903-723-0920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8293111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1750372009OtherPROVIDER'S NPI
TX1750372009OtherPROVIDER'S NPI
TXU87724Medicare UPIN