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General NPI Number Information
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NPI Number | 1396187589
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Entity Type | Organization
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Legal Business Name | LAKE TRAVIS CHIROPRACTIC, PLLC
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Dates
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Enumeration Date | 07/29/2013
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Last Update Date | 10/10/2014
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Provider Practice Location Address
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Address Line | 1603 RANCH ROAD 620 N
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City | LAKEWAY
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State | TX
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Zip | 78734-2693
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Country | US
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Telephone | 512-548-6576
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Fax |
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Provider Business Mailing Address
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Address Line | 6 WINGREEN LOOP
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City | THE HILLS
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State | TX
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Zip | 78738-1522
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Country | US
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Telephone | 512-548-6576
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Fax |
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Authorized Official
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Title or Position | OWNER/SOLE MEMBER
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Name | MARISKA VISSER
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Credential | D.C.
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Telephone | 512-548-6576
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | F0010454
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License Number State | TX
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