Healthcare Provider Details

I. General information

NPI: 1093399875
Provider Name (Legal Business Name): LAWRENCE HARGRAVES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2021
Last Update Date: 05/08/2021
Certification Date: 05/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 40TH ST
OAKLAND CA
94609-2633
US

IV. Provider business mailing address

390 40TH ST
OAKLAND CA
94609-2633
US

V. Phone/Fax

Practice location:
  • Phone: 510-613-0330
  • Fax:
Mailing address:
  • Phone: 510-613-0330
  • 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: