Healthcare Provider Details

I. General information

NPI: 1487620019
Provider Name (Legal Business Name): MICHAEL LEE GARCIA L.A.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 COLLEGE HTS
CISCO TX
76437-1900
US

IV. Provider business mailing address

510 W 11TH ST
CISCO TX
76437-3434
US

V. Phone/Fax

Practice location:
  • Phone: 254-442-5064
  • Fax: 254-442-5100
Mailing address:
  • Phone: 325-439-6168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT3075
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: