Healthcare Provider Details

I. General information

NPI: 1912031188
Provider Name (Legal Business Name): MATTHEW MORGAN MIX D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
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:
Title or Position:
Credential:
Phone: