MEDICARE: LAZENA GLOVER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1053142422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAZENA GLOVER

Provider Business Mailing Address
First Line	:	23015 FM 529 RD STE 200
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77493-5065
Country	:	US
Telephone Number	:	832-283-9085
Fax Number	:

Provider Business Practice Location Address
First Line	:	23015 FM 529 RD STE 200
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77493-5065
Country	:	US
Telephone Number	:	832-283-9085
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2024
Last Update Date	:	08/08/2024

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Directions to “ LAZENA GLOVER ” Practice Location

Language	Start Address	Practice Location

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