Provider Demographics
NPI:1194745943
Name:GEMINI CONCEPTS, INC
Entity type:Organization
Organization Name:GEMINI CONCEPTS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-421-9111
Mailing Address - Street 1:PO BOX 92248
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0103
Mailing Address - Country:US
Mailing Address - Phone:817-421-9111
Mailing Address - Fax:817-421-9222
Practice Address - Street 1:680 N CARROLL AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6475
Practice Address - Country:US
Practice Address - Phone:817-421-9111
Practice Address - Fax:817-421-9222
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEMINI CONCEPTS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-21
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6658111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0005NDOtherBCBS
TX0005NDOtherBCBS