Provider Demographics
NPI:1366054025
Name:IRVIN, DAVID RUSS (DACCM, LAC, LMT)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RUSS
Last Name:IRVIN
Suffix:
Gender:M
Credentials:DACCM, LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7703 COPANO DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-3810
Mailing Address - Country:US
Mailing Address - Phone:737-217-5763
Mailing Address - Fax:
Practice Address - Street 1:2500 W WILLIAM CANNON DR STE 201
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5288
Practice Address - Country:US
Practice Address - Phone:737-217-5763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-23
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2459171100000X
TX100480225700000X
TX1808171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist