Healthcare Provider Details

I. General information

NPI: 1538401021
Provider Name (Legal Business Name): LAUREN KRYSTAL LUCIO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN KRYSTAL GARCIA

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 N GRANDVIEW AVE SUITE 400
ODESSA TX
79761-1600
US

IV. Provider business mailing address

2525 N GRANDVIEW AVE SUITE 400
ODESSA TX
79761-1600
US

V. Phone/Fax

Practice location:
  • Phone: 432-550-4700
  • Fax: 432-550-4715
Mailing address:
  • Phone: 432-550-4700
  • Fax: 432-550-4715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2091639
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3123434
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: