Healthcare Provider Details

I. General information

NPI: 1265502348
Provider Name (Legal Business Name): GAVIN HERBERT CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 WILSHIRE BLVD.
LOS ANGELES CA
90025-1773
US

IV. Provider business mailing address

PO BOX 9889
NEWPORT BEACH CA
92658-1889
US

V. Phone/Fax

Practice location:
  • Phone: 310-479-0960
  • Fax: 310-477-3509
Mailing address:
  • Phone: 949-640-1231
  • Fax: 949-640-9123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. KEITH ROBERT LUMPKIN
Title or Position: PRESIDENT
Credential:
Phone: 949-640-1231