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General NPI Number Information
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NPI Number | 1457269136
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Entity Type | Organization
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Legal Business Name | AVITALITY MEDICAL PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 09/01/2026
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Last Update Date | 09/01/2026
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Provider Practice Location Address
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Address Line | 653 E E ST STE 109
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City | ONTARIO
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State | CA
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Zip | 91764-4257
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Country | US
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Telephone | 909-395-9888
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Fax |
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Provider Business Mailing Address
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Address Line | 653 E E ST STE 109
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City | ONTARIO
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State | CA
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Zip | 91764-4257
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Country | US
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Telephone | 909-395-9888
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LAN LAM
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Credential | PAC
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Telephone | 909-395-9888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 173000000X
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Taxonomy Name | Legal Medicine
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License Number |
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License Number State |
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