Healthcare Provider Details

I. General information

NPI: 1205431632
Provider Name (Legal Business Name): GARY LANE WEITMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 MEMORIAL DR
WACO TX
76711-1329
US

IV. Provider business mailing address

4800 MEMORIAL DR
WACO TX
76711-1329
US

V. Phone/Fax

Practice location:
  • Phone: 254-752-6581
  • Fax:
Mailing address:
  • Phone: 254-752-6581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: