Healthcare Provider Details

I. General information

NPI: 1265856033
Provider Name (Legal Business Name): VERNON MHT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2014
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W ARKANSAS ST
LEESVILLE LA
71446-4752
US

IV. Provider business mailing address

1515 HERITAGE DR SUITE 110
MCKINNEY TX
75069-3256
US

V. Phone/Fax

Practice location:
  • Phone: 855-860-2109
  • Fax:
Mailing address:
  • Phone: 855-860-2109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11793R
License Number StateLA

VIII. Authorized Official

Name: HANNA LUBBOS
Title or Position: OWNER
Credential:
Phone: 337-423-5020