Provider Demographics
NPI:1568733665
Name:SKIDMORE, ADAM EDWARD (LMT)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:EDWARD
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 HOLLY SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77302-3733
Mailing Address - Country:US
Mailing Address - Phone:936-443-1975
Mailing Address - Fax:
Practice Address - Street 1:731 HOLLY SPRINGS DR
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77302-3733
Practice Address - Country:US
Practice Address - Phone:936-443-1975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT111730225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist