Healthcare Provider Details

I. General information

NPI: 1629033907
Provider Name (Legal Business Name): MR. MORRELL J LAVENDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 STOCKTON RD BLDG 624 NAVAL TRAINING CENTER
SAN DIEGO CA
92106-6000
US

IV. Provider business mailing address

2650 STOCKTON RD BLDG 624 NAVAL TRAINING CENTER
SAN DIEGO CA
92106-6000
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-5733
  • Fax: 619-524-0018
Mailing address:
  • Phone: 619-524-5733
  • Fax: 619-524-0018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: