MEDICARE: NOWAITLIST LLC

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	2080P0008X	Pediatric Neurodevelopmental Disabilities Physician
2	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1912787276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOWAITLIST LLC

Provider Business Mailing Address
First Line	:	4323 FM 1878
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-0318
Country	:	US
Telephone Number	:	512-623-0641
Fax Number	:

Provider Business Practice Location Address
First Line	:	4323 FM 1878
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-0318
Country	:	US
Telephone Number	:	512-623-0641
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LUKE DODSON
Credential	:
Telephone Number	:	512-623-0641

Provider Enumeration Date	:	10/04/2023
Last Update Date	:	10/04/2023

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Directions to “NOWAITLIST LLC ” Practice Location

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