Healthcare Provider Details

I. General information

NPI: 1306070842
Provider Name (Legal Business Name): LAWRENCE D. GUAJARDO IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 54 BOX 1989
APO AE
09601-0020
US

IV. Provider business mailing address

PSC 54 BOX 1989
APO AE
09601-0020
US

V. Phone/Fax

Practice location:
  • Phone: 13615283881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License NumberB1055518
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: