MEDICARE: LAUREN MICHEL ESTRIDGE MS, ATC, LAT

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	2255A2300X	Athletic Trainer	AT5696	TX

General Provider Information

NPI Number	:	1871077669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREN MICHEL ESTRIDGE MS, ATC, LAT

Provider Business Mailing Address
First Line	:	1401 S BYRD AVE
Second Line	:
City	:	SHEPHERD
State	:	TX
Zip	:	77371-3582
Country	:	US
Telephone Number	:	936-628-3371
Fax Number	:	936-628-6986

Provider Business Practice Location Address
First Line	:	1401 S BYRD AVE
Second Line	:
City	:	SHEPHERD
State	:	TX
Zip	:	77371-3582
Country	:	US
Telephone Number	:	936-628-3371
Fax Number	:	936-628-6986

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

Provider Enumeration Date	:	09/18/2018
Last Update Date	:	09/18/2018

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