MEDICARE: MR. MARK LYNN PHILLIPS A.T.C., L.A.T.

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	174400000X	Specialist	AT0481	TX

General Provider Information

NPI Number	:	1558336297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK LYNN PHILLIPS A.T.C., L.A.T.

Provider Business Mailing Address
First Line	:	21610 PARKER RD
Second Line	:
City	:	TOMBALL
State	:	TX
Zip	:	77377-6037
Country	:	US
Telephone Number	:	281-255-3970
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 RAIDER CIRCLE
Second Line	:	NORTHBROOK HIGH SCHOOL
City	:	HOUSTON
State	:	TX
Zip	:	77080
Country	:	US
Telephone Number	:	713-365-4430
Fax Number	:

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

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	07/08/2007

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