=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285034850
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKKO OPTIMAL HEALTH,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2014
-----------------------------------------------------
Last Update Date | 09/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 W 15TH ST
-----------------------------------------------------
City | HEREFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79045-2820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-349-9331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2061
-----------------------------------------------------
City | HEREFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79045-2061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-349-9331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT J LAKKO
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 806-349-9331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | P7794
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | P7794
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------