MEDICARE: MR. LAWRENCE DOUGLAS SAMPSON JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator		MS

General Provider Information

NPI Number	:	1124409412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LAWRENCE DOUGLAS SAMPSON JR.

Provider Business Mailing Address
First Line	:	6204 N STATE ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39213-9731
Country	:	US
Telephone Number	:	202-765-8092
Fax Number	:

Provider Business Practice Location Address
First Line	:	6204 N STATE ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39213-9731
Country	:	US
Telephone Number	:	202-765-8092
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2015
Last Update Date	:	06/12/2015

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