Healthcare Provider Details

I. General information

NPI: 1427182690
Provider Name (Legal Business Name): MIX FAMILY CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 MAIN ST
BASTROP TX
78602-3807
US

IV. Provider business mailing address

807 MAIN ST
BASTROP TX
78602-3807
US

V. Phone/Fax

Practice location:
  • Phone: 512-321-9200
  • Fax: 512-321-9201
Mailing address:
  • Phone: 512-321-9200
  • Fax: 512-321-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number10313
License Number StateTX

VIII. Authorized Official

Name: DR. MATTHEW MIX
Title or Position: PRESIDENT
Credential: D.C.
Phone: 512-321-9200