=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720806169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REGINALD JEROME LAUDERMILL I
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2024
-----------------------------------------------------
Last Update Date | 10/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 E MANCHESTER BLVD
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90301-1910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-331-9268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 E MANCHESTER BLVD
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90301-1910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-331-9268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number | 841948112
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------