Healthcare Provider Details

I. General information

NPI: 1851823165
Provider Name (Legal Business Name): LAUREN WILMOT LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 SHORE DR STE 104
WORCESTER MA
01605-3154
US

IV. Provider business mailing address

72 STREETER RD
PAXTON MA
01612-1108
US

V. Phone/Fax

Practice location:
  • Phone: 508-853-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number7114
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: