MEDICARE: LAVICA LANE LM, CPM

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	176B00000X	Midwife	99284	TX

General Provider Information

NPI Number	:	1811433774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAVICA LANE LM, CPM

Provider Business Mailing Address
First Line	:	814 DALWORTH ST
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75050-5545
Country	:	US
Telephone Number	:	972-263-0299
Fax Number	:	972-642-4171

Provider Business Practice Location Address
First Line	:	814 DALWORTH ST
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75050-5545
Country	:	US
Telephone Number	:	972-263-0299
Fax Number	:	972-642-4171

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

Provider Enumeration Date	:	01/16/2017
Last Update Date	:	01/16/2017

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Directions to “ LAVICA LANE LM, CPM” Practice Location

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