Provider Demographics
NPI:1154552834
Name:PRO-ADJUSTER CHIROPRACTIC CLINIC, INC.
Entity type:Organization
Organization Name:PRO-ADJUSTER CHIROPRACTIC CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESA
Authorized Official - Middle Name:GILLEZEAU
Authorized Official - Last Name:ANSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC, RN
Authorized Official - Phone:972-291-1992
Mailing Address - Street 1:103 E BELT LINE RD
Mailing Address - Street 2:STE. G
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-2274
Mailing Address - Country:US
Mailing Address - Phone:972-291-1992
Mailing Address - Fax:972-291-1163
Practice Address - Street 1:103 E BELT LINE RD
Practice Address - Street 2:STE. G
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2274
Practice Address - Country:US
Practice Address - Phone:972-291-1992
Practice Address - Fax:972-291-1163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8020111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A5786Medicare PIN