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General NPI Number Information
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NPI Number | 1750809513
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Entity Type | Organization
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Legal Business Name | 620 CHIROPRACTIC & LONGEVITY CENTER, PLLC
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Dates
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Enumeration Date | 08/31/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1603 RANCH ROAD 620 N STE 200
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City | LAKEWAY
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State | TX
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Zip | 78734-2324
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Country | US
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Telephone | 512-266-8100
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Fax | 512-266-8103
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Provider Business Mailing Address
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Address Line | 1603 RANCH ROAD 620 N STE 200
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City | LAKEWAY
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State | TX
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Zip | 78734-2324
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Country | US
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Telephone | 512-266-8100
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Fax | 512-266-8103
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Authorized Official
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Title or Position | OWNER
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Name | DR. MICAH WYNN PITTMAN
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Credential | DC
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Telephone | 425-457-1980
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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 | 13544
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License Number State | TX
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