=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578637997
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAWRENCE AMOS LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 06/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 FREE BRIDGE LN
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22911-8446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-338-0644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 937 TILMAN RD
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22901-6338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-338-0644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | MA0025517
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------