=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003496811
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYLOR JAMES OVERTON MAT, LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2021
-----------------------------------------------------
Last Update Date | 04/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2621 DRIVE OF CHAMPIONS
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-775-0519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4824 72ND ST
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-921-9877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | AT6556
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------