Healthcare Provider Details

I. General information

NPI: 1508961855
Provider Name (Legal Business Name): CHILDRENS CLINIC OF LUFKIN PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 GENE SAMFORD DR
LUFKIN TX
75904
US

IV. Provider business mailing address

205 GENE SAMFORD DR
LUFKIN TX
75904
US

V. Phone/Fax

Practice location:
  • Phone: 936-634-2214
  • Fax: 936-639-9660
Mailing address:
  • Phone: 936-634-2214
  • Fax: 936-639-9660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY L GLASS
Title or Position: OWNER
Credential: MD
Phone: 936-634-2214