Healthcare Provider Details

I. General information

NPI: 1164091740
Provider Name (Legal Business Name): LAVANTA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MARINA BLVD
PITTSBURG CA
94565-2068
US

IV. Provider business mailing address

5000 WOODMONT WAY
ANTIOCH CA
94531-8142
US

V. Phone/Fax

Practice location:
  • Phone: 925-252-1111
  • Fax:
Mailing address:
  • Phone: 925-778-9498
  • Fax: 925-778-9498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: