Healthcare Provider Details

I. General information

NPI: 1225824030
Provider Name (Legal Business Name): MYSTIC WATERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2025
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14523 RIDGETOP TER
AUSTIN TX
78732-1037
US

IV. Provider business mailing address

14523 RIDGETOP TER
AUSTIN TX
78732-1037
US

V. Phone/Fax

Practice location:
  • Phone: 760-815-6923
  • Fax:
Mailing address:
  • Phone: 760-815-6923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

Name: YOLANDE RADEMEYER
Title or Position: MIDWIFE/OWNER
Credential: LM
Phone: 760-815-6923