Provider Demographics
NPI:1154562031
Name:INJURY ONE OF WICHITA FALLS, LLC
Entity type:Organization
Organization Name:INJURY ONE OF WICHITA FALLS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NAT
Authorized Official - Middle Name:E
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-692-6666
Mailing Address - Street 1:5931 DESCO DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-1604
Mailing Address - Country:US
Mailing Address - Phone:214-563-5122
Mailing Address - Fax:214-361-1235
Practice Address - Street 1:2611 PLAZA PKWY
Practice Address - Street 2:SUITE 302
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-3886
Practice Address - Country:US
Practice Address - Phone:214-563-5122
Practice Address - Fax:214-361-1235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15520101YP2500X
TX32981103T00000X
TX33427103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty