MEDICARE: MRS. VICKI L LANDRY 1ST ASSISTANT

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	246ZS0410X	Surgical Technologist	06-246	TX

General Provider Information

NPI Number	:	1619160827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VICKI L LANDRY 1ST ASSISTANT

Provider Business Mailing Address
First Line	:	6049 JADE AVE
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77640-1132
Country	:	US
Telephone Number	:	409-736-3584
Fax Number	:

Provider Business Practice Location Address
First Line	:	5500 39TH ST
Second Line	:
City	:	GROVES
State	:	TX
Zip	:	77619-2905
Country	:	US
Telephone Number	:	409-962-5733
Fax Number	:

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

Provider Enumeration Date	:	08/21/2007
Last Update Date	:	08/21/2007

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