Provider Demographics
NPI:1366930208
Name:633 CHIROPRACTIC LLC
Entity type:Organization
Organization Name:633 CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IPERLITTA
Authorized Official - Middle Name:VANCE
Authorized Official - Last Name:LOLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:225-522-1380
Mailing Address - Street 1:308 N GRAY ST # B
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76541-5245
Mailing Address - Country:US
Mailing Address - Phone:225-522-1380
Mailing Address - Fax:888-620-8147
Practice Address - Street 1:308 N GRAY ST # B
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541-5245
Practice Address - Country:US
Practice Address - Phone:225-522-1380
Practice Address - Fax:888-620-8147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-26
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13635111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1780059295OtherNPI
TX392409401Medicaid