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General NPI Number Information
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NPI Number | 1962775718
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Entity Type | Organization
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Legal Business Name | AQUA HAVEN CHIROPRACTIC
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Dates
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Enumeration Date | 02/09/2012
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Last Update Date | 02/09/2012
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Provider Practice Location Address
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Address Line | 107 RANCH ROAD 620 SOUTH SUITE 105
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City | LAKEWAY
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State | TX
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Zip | 78734-3901
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Country | US
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Telephone | 512-266-7684
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Fax |
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Provider Business Mailing Address
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Address Line | 4501 WHISPER TRL
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City | BELTON
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State | TX
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Zip | 76513-9521
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DOCTOR OF CHIROPRACTIC
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Name | JINGER R POTH
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Credential | D.C.
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Telephone | 512-508-0632
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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 | 10344
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License Number State | TX
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