Provider Demographics
NPI:1447250055
Name:LAURIE DOWELL
Entity type:Organization
Organization Name:LAURIE DOWELL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:CP LP FAA OP
Authorized Official - Phone:903-592-4737
Mailing Address - Street 1:1910 ESE LOOP323
Mailing Address - Street 2:#119
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8337
Mailing Address - Country:US
Mailing Address - Phone:903-542-4737
Mailing Address - Fax:903-535-9028
Practice Address - Street 1:704 S BOIS D ARC AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1503
Practice Address - Country:US
Practice Address - Phone:903-592-4737
Practice Address - Fax:903-535-9028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX466335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1637571Medicaid
TX$$$$$$$$$OtherSSN #
TX461845206OtherSSN #