Basic Information
Provider Information | |||||||||
NPI: | 1649637109 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIRK | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | KEENAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.C. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KEENAN | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 700688 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782700688 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2104777654 | ||||||||
FaxNumber: | 2104680682 | ||||||||
Practice Location | |||||||||
Address1: | 123 N POST OAK LN STE 420 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770247785 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004046050 | ||||||||
FaxNumber: | 8663133397 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2016 | ||||||||
LastUpdateDate: | 07/19/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 0104-557306 | VA | N |   | Chiropractic Providers | Chiropractor |   | 111N00000X | 13473 | TX | Y |   | Chiropractic Providers | Chiropractor |   |
ID Information
ID | Type | State | Issuer | Description | 13473 | 01 | TX | TEXAS BOARD OF CHIROPRACTIC EXAMINERS | OTHER |