Basic Information
| Provider Information | |||||||||
| NPI: | 1376675876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAILES | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NICKEL | ||||||||
| OtherFirstName: | LORI | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8960 HILLSIDE RD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791197323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063541000 | ||||||||
| FaxNumber: | 8063516950 | ||||||||
| Practice Location | |||||||||
| Address1: | 8960 HILLSIDE RD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791197323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063541000 | ||||||||
| FaxNumber: | 8063516950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2007 | ||||||||
| LastUpdateDate: | 10/10/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | R3667 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 0533758 | KS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200619370B | 05 | KS | MEDICAID |