Healthcare Provider Details

I. General information

NPI: 1790828671
Provider Name (Legal Business Name): MR. MARK THOMAS LOVELADY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1664 MAPLEWOOD ST
LA VERNE CA
91750-3929
US

IV. Provider business mailing address

1664 MAPLEWOOD ST
LA VERNE CA
91750-3929
US

V. Phone/Fax

Practice location:
  • Phone: 626-433-1311
  • Fax: 626-433-1313
Mailing address:
  • Phone: 626-433-1311
  • Fax: 626-433-1313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number33201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: