=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528443298
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORI GRISHAM MT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2015
-----------------------------------------------------
Last Update Date | 07/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 751 HEBRON PKWY SUITE 110
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75057-5055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-453-1597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 OAKWOOD LN
-----------------------------------------------------
City | HICKORY CREEK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75065-7673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-453-1597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246QL0900X
-----------------------------------------------------
Taxonomy Name | Laboratory Management Specialist/Technologist
-----------------------------------------------------
License Number | 69721
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------