Provider Demographics
NPI:1891881942
Name:LANDAVAZO, IMOGENE YVONNE (DC)
Entity Type:Individual
Prefix:
First Name:IMOGENE
Middle Name:YVONNE
Last Name:LANDAVAZO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 EVERHART
Mailing Address - Street 2:STE B3
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413
Mailing Address - Country:US
Mailing Address - Phone:361-854-2440
Mailing Address - Fax:361-854-2477
Practice Address - Street 1:6601 EVERHART
Practice Address - Street 2:STE B3
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413
Practice Address - Country:US
Practice Address - Phone:361-854-2440
Practice Address - Fax:361-854-2477
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3071111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001208001Medicaid
TX601297Medicare ID - Type Unspecified
TX001208001Medicaid