1194003921 NPI number — OPTIMAL WELLNESS CHIROPRACTIC PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194003921 NPI number — OPTIMAL WELLNESS CHIROPRACTIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMAL WELLNESS CHIROPRACTIC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194003921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 81284
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78708-1284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-343-9831
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 FM 685
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
PFLUGERVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78660-7536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-343-9831
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CORONADO
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER / PROVIDER
Authorized Official Telephone Number:
956-343-9831

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  10547 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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