Healthcare Provider Details

I. General information

NPI: 1174923890
Provider Name (Legal Business Name): LAVONDE BARNES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 E ALBERTONI ST 200
CARSON CA
90746-1539
US

IV. Provider business mailing address

11815 SILVER LOOP
MIRA LOMA CA
91752-4401
US

V. Phone/Fax

Practice location:
  • Phone: 310-217-0616
  • Fax:
Mailing address:
  • Phone: 951-817-8985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: