Healthcare Provider Details

I. General information

NPI: 1124297254
Provider Name (Legal Business Name): CENTRAL TEXAS WELLLNESS CENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 S MEDINA ST
LOCKHART TX
78644-3259
US

IV. Provider business mailing address

1105 S MEDINA ST
LOCKHART TX
78644-3259
US

V. Phone/Fax

Practice location:
  • Phone: 512-398-6262
  • Fax: 512-398-6040
Mailing address:
  • Phone: 512-398-6262
  • Fax: 512-398-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC6919
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1100634
License Number StateTX

VIII. Authorized Official

Name: DR. DONOVAN L. THOMAS
Title or Position: OWNER/SOLE MEMBER
Credential: DC
Phone: 512-398-6262