Healthcare Provider Details

I. General information

NPI: 1689603805
Provider Name (Legal Business Name): LIBERTY DAYTON FOOT & ANKLE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 06/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 GRAND AVE
LIBERTY TX
77575-4705
US

IV. Provider business mailing address

PO BOX 1160
LIBERTY TX
77575-1160
US

V. Phone/Fax

Practice location:
  • Phone: 936-336-2633
  • Fax: 936-336-6031
Mailing address:
  • Phone: 281-444-4114
  • Fax: 281-453-1269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number506
License Number StateTX

VIII. Authorized Official

Name: DR. LAWRENCE S MACTAVISH
Title or Position: PHYSICIAN OWNER
Credential: D.P.M.
Phone: 936-336-2633