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General NPI Number Information
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NPI Number | 1689603805
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Entity Type | Organization
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Legal Business Name | LIBERTY DAYTON FOOT & ANKLE CENTER
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Dates
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Enumeration Date | 07/01/2006
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Last Update Date | 06/19/2009
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Provider Practice Location Address
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Address Line | 1825 GRAND AVE
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City | LIBERTY
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State | TX
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Zip | 77575-4705
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Country | US
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Telephone | 936-336-2633
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Fax | 936-336-6031
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Provider Business Mailing Address
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Address Line | PO BOX 1160
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City | LIBERTY
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State | TX
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Zip | 77575-1160
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Country | US
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Telephone | 281-444-4114
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Fax | 281-453-1269
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Authorized Official
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Title or Position | PHYSICIAN OWNER
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Name | DR. LAWRENCE S MACTAVISH
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Credential | D.P.M.
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Telephone | 936-336-2633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 506
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License Number State | TX
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