Provider Demographics
NPI:1023602406
Name:VIDALES, JUAN C (DC)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:VIDALES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 S GREENVILLE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-5046
Mailing Address - Country:US
Mailing Address - Phone:972-644-6336
Mailing Address - Fax:972-644-7247
Practice Address - Street 1:850 S GREENVILLE AVE STE 104
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-5046
Practice Address - Country:US
Practice Address - Phone:972-644-6336
Practice Address - Fax:972-644-7247
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9039111N00000X
TX15543111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor