Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 6399 | TX |
NPI | 1003018284 |
---|---|
Provider Name | Johnny Lee Wakefield |
First Address | Spring, TX 77380 |
Second Address | Spring, TX 77380 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
63999 | DC LICENSE (01) | TX |