MEDICARE: DR. LAVERN LASETER D.C.

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	111N00000X	Chiropractor	12043	TX

General Provider Information

NPI Number	:	1366705717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAVERN LASETER D.C.

Provider Business Mailing Address
First Line	:	4925 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1407
Country	:	US
Telephone Number	:	817-263-9700
Fax Number	:	817-263-9706

Provider Business Practice Location Address
First Line	:	4925 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1407
Country	:	US
Telephone Number	:	817-263-9700
Fax Number	:	817-263-9706

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

Provider Enumeration Date	:	06/20/2012
Last Update Date	:	06/20/2012

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