Provider Demographics
NPI:1790385391
Name:SOUTH TEXAS SPORTS CHIROPRACTIC
Entity Type:Organization
Organization Name:SOUTH TEXAS SPORTS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKKEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHAMONDES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-512-9903
Mailing Address - Street 1:7534 LASSO DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7534 LASSO DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414
Practice Address - Country:US
Practice Address - Phone:813-512-9903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-01
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty