1902819436 NPI number — LORA SERAPHIN FITZGERALD MA, ATC

Table of content: LORA SERAPHIN FITZGERALD MA, ATC (NPI 1902819436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902819436 NPI number — LORA SERAPHIN FITZGERALD MA, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
LORA
Provider Middle Name:
SERAPHIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902819436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5524 LA BANDERA TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENBROOK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76126-1843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-212-3849
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1651 W ROSEDALE ST
Provider Second Line Business Practice Location Address:
STE. 200
Provider Business Practice Location Address City Name:
FT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-7437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-335-4316
Provider Business Practice Location Address Fax Number:
817-336-2504
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 050202041 . This is a "NATABOC" identifier . This identifiers is of the category "OTHER".




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