Provider Demographics
NPI:1750809513
Name:620 CHIROPRACTIC & LONGEVITY CENTER, PLLC
Entity type:Organization
Organization Name:620 CHIROPRACTIC & LONGEVITY CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:WYNN
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-457-1980
Mailing Address - Street 1:1603 RANCH ROAD 620 N STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-2324
Mailing Address - Country:US
Mailing Address - Phone:512-266-8100
Mailing Address - Fax:512-266-8103
Practice Address - Street 1:1603 RANCH ROAD 620 N STE 200
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-2324
Practice Address - Country:US
Practice Address - Phone:512-266-8100
Practice Address - Fax:512-266-8103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13544111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty