Healthcare Provider Details

I. General information

NPI: 1083276810
Provider Name (Legal Business Name): LAUREN NICOLE TATLOCK OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 E DOUGLAS AVE
WICHITA KS
67202-3510
US

IV. Provider business mailing address

926 E DOUGLAS AVE
WICHITA KS
67202-3510
US

V. Phone/Fax

Practice location:
  • Phone: 316-247-6515
  • Fax:
Mailing address:
  • Phone: 316-217-7459
  • Fax: 678-928-0651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2019018294
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2109
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: