Provider Demographics
NPI:1144342064
Name:INTEGRATED CHIROPRACTIC WELLNESS, PLLC
Entity type:Organization
Organization Name:INTEGRATED CHIROPRACTIC WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:UDE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-970-8883
Mailing Address - Street 1:1600 W 38TH ST
Mailing Address - Street 2:SUITE 412
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6400
Mailing Address - Country:US
Mailing Address - Phone:512-970-8883
Mailing Address - Fax:
Practice Address - Street 1:1600 W 38TH ST
Practice Address - Street 2:SUITE 412
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6400
Practice Address - Country:US
Practice Address - Phone:512-970-8883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10555111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0012PNOtherBCBS ID
TX0012PNOtherBCBS ID