Healthcare Provider Details

I. General information

NPI: 1689837395
Provider Name (Legal Business Name): MARC K LAPHAM CRTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 MONTE VISTA DR
BIG BEAR CITY CA
92314-9050
US

IV. Provider business mailing address

PO BOX 1679
BIG BEAR CITY CA
92314-1679
US

V. Phone/Fax

Practice location:
  • Phone: 909-585-1339
  • Fax:
Mailing address:
  • Phone: 909-585-1339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number102727
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: