Healthcare Provider Details

I. General information

NPI: 1285746412
Provider Name (Legal Business Name): LAURA L DAILEY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA V LANE

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2329 N 39TH ST BMA WACO - CKD SERVICES
WACO TX
76708-3003
US

IV. Provider business mailing address

2329 N 39TH ST
WACO TX
76708-3003
US

V. Phone/Fax

Practice location:
  • Phone: 254-752-5503
  • Fax: 254-752-4844
Mailing address:
  • Phone: 254-752-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberDT04918
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: