Healthcare Provider Details

I. General information

NPI: 1033169735
Provider Name (Legal Business Name): DENNIS EDWARD PRUSS ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 S LOOP 289
LUBBOCK TX
79424-2206
US

IV. Provider business mailing address

8605 OXFORD AVE
LUBBOCK TX
79423-1925
US

V. Phone/Fax

Practice location:
  • Phone: 806-792-7200
  • Fax: 806-792-7225
Mailing address:
  • Phone: 806-783-8605
  • Fax: 806-783-8604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0459
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: