Healthcare Provider Details

I. General information

NPI: 1003496811
Provider Name (Legal Business Name): TAYLOR JAMES OVERTON MAT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 04/14/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 DRIVE OF CHAMPIONS
LUBBOCK TX
79414
US

IV. Provider business mailing address

4824 72ND ST
LUBBOCK TX
79424-2102
US

V. Phone/Fax

Practice location:
  • Phone: 972-775-0519
  • Fax:
Mailing address:
  • Phone: 972-921-9877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT6556
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: