1003113358 NPI number — DR. DAVID ALAN LAVIN P.T.,D.P.T.,C.S.C.S.

Table of content: DR. DAVID ALAN LAVIN P.T.,D.P.T.,C.S.C.S. (NPI 1003113358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003113358 NPI number — DR. DAVID ALAN LAVIN P.T.,D.P.T.,C.S.C.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAVIN
Provider First Name:
DAVID
Provider Middle Name:
ALAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.,D.P.T.,C.S.C.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003113358
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 949
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30162-0949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-236-2774
Provider Business Mailing Address Fax Number:
706-802-1408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1897 ISLAND WALK WAY
Provider Second Line Business Practice Location Address:
UNIT 6
Provider Business Practice Location Address City Name:
FERNANDINA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32034-1948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-261-4664
Provider Business Practice Location Address Fax Number:
904-261-5852
Provider Enumeration Date:
02/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 25768 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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