Provider Demographics
NPI:1396187589
Name:LAKE TRAVIS CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:LAKE TRAVIS CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARISKA
Authorized Official - Middle Name:
Authorized Official - Last Name:VISSER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-548-6576
Mailing Address - Street 1:6 WINGREEN LOOP
Mailing Address - Street 2:
Mailing Address - City:THE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78738-1522
Mailing Address - Country:US
Mailing Address - Phone:512-548-6576
Mailing Address - Fax:
Practice Address - Street 1:1603 RANCH ROAD 620 N
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-2693
Practice Address - Country:US
Practice Address - Phone:512-548-6576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-29
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0010454111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty