Healthcare Provider Details

I. General information

NPI: 1174385348
Provider Name (Legal Business Name): DAVID CLAY LAVERY RCS,RVS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2024
Last Update Date: 01/24/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 NE 191ST ST
MIAMI FL
33179-3899
US

IV. Provider business mailing address

382 NE 191ST ST
MIAMI FL
33179-3899
US

V. Phone/Fax

Practice location:
  • Phone: 352-514-6432
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number00097812
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: