=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265856033
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VERNON MHT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2014
-----------------------------------------------------
Last Update Date | 08/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 W ARKANSAS ST
-----------------------------------------------------
City | LEESVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71446-4752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-860-2109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 HERITAGE DR SUITE 110
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75069-3256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-860-2109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HANNA LUBBOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-423-5020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 11793R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------