MEDICARE: MR. MARK LANE

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1932791431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK LANE

Provider Business Mailing Address
First Line	:	1033 VIA CONTENTA
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92029-7211
Country	:	US
Telephone Number	:	760-708-2105
Fax Number	:

Provider Business Practice Location Address
First Line	:	1033 VIA CONTENTA
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92029-7211
Country	:	US
Telephone Number	:	760-708-2105
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2021
Last Update Date	:	02/05/2021

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Directions to “ MR. MARK LANE ” Practice Location

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