=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114218708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIAN SPORE DO PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2011
-----------------------------------------------------
Last Update Date | 04/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3804 S MEDFORD DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75901-5780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-634-2231
-----------------------------------------------------
Fax | 936-634-8012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3804 S MEDFORD DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75901-5780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-634-2231
-----------------------------------------------------
Fax | 936-634-8012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DO
-----------------------------------------------------
Name | DR. BRIAN SPORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 936-634-2231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | K5703
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------