=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225280704
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONGVIEW NEUROLOGICAL CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2008
-----------------------------------------------------
Last Update Date | 10/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2441 E US HIGHWAY 377 SUITE 105
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76049-5991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-235-0319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2441 E US HIGHWAY 377 SUITE 105
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76049-5991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-235-0319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | LIANA E DAWSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 903-235-0319
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084V0102X
-----------------------------------------------------
Taxonomy Name | Vascular Neurology Physician
-----------------------------------------------------
License Number | K0451
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------