Healthcare Provider Details

I. General information

NPI: 1184054397
Provider Name (Legal Business Name): BILLY RAY LAXTON JR. M.ED, LAT, ATC,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 S 31ST ST
TEMPLE TX
76508-0001
US

IV. Provider business mailing address

2401 S 31ST ST
TEMPLE TX
76508-0001
US

V. Phone/Fax

Practice location:
  • Phone: 254-724-2421
  • Fax: 254-724-1866
Mailing address:
  • Phone: 254-724-2421
  • Fax: 254-724-1866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT1120
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: