=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891000139
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOREE MCCARY ATC, LAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2010
-----------------------------------------------------
Last Update Date | 08/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1936 NORTH ST SFA SPORTS MEDICINE CLINIC
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75965-3940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-468-4550
-----------------------------------------------------
Fax | 936-468-4052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 13010 SFA STATION
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75962-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-468-4550
-----------------------------------------------------
Fax | 936-468-4052
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | AT1184
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------