Healthcare Provider Details

I. General information

NPI: 1962905968
Provider Name (Legal Business Name): BRANDON LAWRENCE MLS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 CAMPBELL AVE
WEST HAVEN CT
06516-2770
US

IV. Provider business mailing address

409 EDGEWOOD AVE
NEW HAVEN CT
06511-4013
US

V. Phone/Fax

Practice location:
  • Phone: 203-932-5711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: