Healthcare Provider Details

I. General information

NPI: 1245881630
Provider Name (Legal Business Name): 772, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 HARGRAVES DR STE E200
AUSTIN TX
78737-4836
US

IV. Provider business mailing address

166 HARGRAVES DR STE E200
AUSTIN TX
78737-4836
US

V. Phone/Fax

Practice location:
  • Phone: 512-766-4000
  • Fax:
Mailing address:
  • Phone: 512-766-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: SARIAH D WELCH LOPEZ
Title or Position: OWNER
Credential:
Phone: 512-905-5629