Provider Demographics
NPI:1326403718
Name:RATIONAL LONGEVITY MEDICINE & WELLNESS, PLLC
Entity Type:Organization
Organization Name:RATIONAL LONGEVITY MEDICINE & WELLNESS, PLLC
Other - Org Name:RATIONAL LONGEVITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:KRISTINA
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:323-251-7360
Mailing Address - Street 1:4101 MARATHON BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3719
Mailing Address - Country:US
Mailing Address - Phone:512-323-9222
Mailing Address - Fax:512-323-9232
Practice Address - Street 1:4200 EAST STAN SCHLUETER LOOP
Practice Address - Street 2:STE E
Practice Address - City:COLLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542
Practice Address - Country:US
Practice Address - Phone:888-788-2225
Practice Address - Fax:512-323-9232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-29
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty