Healthcare Provider Details

I. General information

NPI: 1578637997
Provider Name (Legal Business Name): LAWRENCE AMOS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 FREE BRIDGE LN
CHARLOTTESVILLE VA
22911-8446
US

IV. Provider business mailing address

937 TILMAN RD
CHARLOTTESVILLE VA
22901-6338
US

V. Phone/Fax

Practice location:
  • Phone: 802-338-0644
  • Fax:
Mailing address:
  • Phone: 802-338-0644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberMA0025517
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: