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NPI Code Detail

MEDICARE: LESA ENLOW OTR

MEDICARE: LESA ENLOW OTR
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
1225X00000XOccupational Therapist679TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
10048342OTHERTXBLUE LINK #
2679OTHERTXHUMANA
383239TOTHERTXBCBS PROVIDER #
4125047OTHERTXSUPERIOR ID #

General Provider Information

NPI Number : 1891779419
Entity Type Code : Individual
Provider Name (Legal Business Name) : LESA ENLOW OTR
Provider Business Mailing Address
First Line : 1005 MIDWESTERN PKWY
Second Line :
City : WICHITA FALLS
State : TX
Zip : 76302-2211
Country : US
Telephone Number : 940-322-0771
Fax Number : 940-766-4943
Provider Business Practice Location Address
First Line : 1005 MIDWESTERN PKWY
Second Line :
City : WICHITA FALLS
State : TX
Zip : 76302-2211
Country : US
Telephone Number : 940-322-0771
Fax Number : 940-766-4943
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/06/2005
Last Update Date : 07/08/2007

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Directions to “ LESA ENLOW OTR” Practice Location

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