Healthcare Provider Details

I. General information

NPI: 1346511433
Provider Name (Legal Business Name): SOUR LAKE HEALTH & MEDICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 SIXTH STREET
SOUR LAKE TX
77659-1870
US

IV. Provider business mailing address

PO BOX 429
SOUR LAKE TX
77659-0429
US

V. Phone/Fax

Practice location:
  • Phone: 409-287-4100
  • Fax: 409-287-4105
Mailing address:
  • Phone: 409-287-4100
  • Fax: 409-287-4105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number712554
License Number StateTX

VIII. Authorized Official

Name: MRS. LACEY GUEDRY
Title or Position: OWNER
Credential: MSN, APRN, FNP-C
Phone: 409-287-4100