Provider Demographics
NPI:1063902120
Name:INNATE GENESIS LLC
Entity type:Organization
Organization Name:INNATE GENESIS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCE
Authorized Official - Middle Name:
Authorized Official - Last Name:METHOT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-387-8733
Mailing Address - Street 1:115 SUNDANCE PKWY STE 340
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-7840
Mailing Address - Country:US
Mailing Address - Phone:512-387-8733
Mailing Address - Fax:512-387-8733
Practice Address - Street 1:115 SUNDANCE PKWY STE 340
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-7840
Practice Address - Country:US
Practice Address - Phone:512-387-8733
Practice Address - Fax:512-387-8733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty