Healthcare Provider Details

I. General information

NPI: 1194337352
Provider Name (Legal Business Name): MONTREL LAWRENCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10776 FREMONT ST
YUCAIPA CA
92399-9630
US

IV. Provider business mailing address

10776 FREMONT ST
YUCAIPA CA
92399-9630
US

V. Phone/Fax

Practice location:
  • Phone: 909-797-0114
  • Fax:
Mailing address:
  • Phone: 909-797-0114
  • 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: