Provider Demographics
NPI:1962775718
Name:AQUA HAVEN CHIROPRACTIC
Entity type:Organization
Organization Name:AQUA HAVEN CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:JINGER
Authorized Official - Middle Name:R
Authorized Official - Last Name:POTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-508-0632
Mailing Address - Street 1:4501 WHISPER TRL
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-9521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 RANCH ROAD 620 SOUTH
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-3901
Practice Address - Country:US
Practice Address - Phone:512-266-7684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10344111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty