1861469512 NPI number — MR. MICHAEL ALAN WATERS LAT, ATC, CSCS

Table of content: MR. MICHAEL ALAN WATERS LAT, ATC, CSCS (NPI 1861469512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861469512 NPI number — MR. MICHAEL ALAN WATERS LAT, ATC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERS
Provider First Name:
MICHAEL
Provider Middle Name:
ALAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LAT, ATC, CSCS
Provider Gender Code:
M

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:
1861469512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
906 WILLOW OAK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DIBOLL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75941-9773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-829-4798
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 S. MEDFORD DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUFKIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75901-5245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-632-7656
Provider Business Practice Location Address Fax Number:
936-634-1091
Provider Enumeration Date:
03/01/2006

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: 174400000X , with the licence number:  AT0945 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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