Provider Demographics
NPI:1992113997
Name:LANDAVAZO CHIROPRACTIC
Entity type:Organization
Organization Name:LANDAVAZO CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IMOGENE
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:LANDAVAZO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:361-854-2440
Mailing Address - Street 1:PO BOX 271248
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78427-1248
Mailing Address - Country:US
Mailing Address - Phone:361-854-2440
Mailing Address - Fax:361-854-2477
Practice Address - Street 1:6009 S STAPLES ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-2901
Practice Address - Country:US
Practice Address - Phone:361-854-2440
Practice Address - Fax:361-854-2477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT14317Medicare UPIN