Provider Demographics
NPI:1225855737
Name:WAVELENGTH CHIROPRACTIC LLC
Entity type:Organization
Organization Name:WAVELENGTH CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-515-3336
Mailing Address - Street 1:12239 QUEENSTON BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-5333
Mailing Address - Country:US
Mailing Address - Phone:346-327-6079
Mailing Address - Fax:
Practice Address - Street 1:12239 QUEENSTON BLVD STE F
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-5333
Practice Address - Country:US
Practice Address - Phone:346-327-6079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty