Healthcare Provider Details

I. General information

NPI: 1942561139
Provider Name (Legal Business Name): TIMOTHY SPRADLING ABC-BOC LO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 08/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3719 24TH ST
LUBBOCK TX
79410-2015
US

IV. Provider business mailing address

3719 24TH ST
LUBBOCK TX
79410-2015
US

V. Phone/Fax

Practice location:
  • Phone: 806-792-0395
  • Fax: 806-792-0396
Mailing address:
  • Phone: 806-792-0395
  • Fax: 806-792-0396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number170
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: