1720210289 NPI number — LANCE E.GRAVELY, M.D., INC.

Table of content: DR. JENNIFER THOMAS MIRABELLI DMD, MSD (NPI 1164591863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720210289 NPI number — LANCE E.GRAVELY, M.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LANCE E.GRAVELY, M.D., INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LANCE E. GRAVELY, M.D., INC.
Provider Other Organization Name Type Code:
3
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:
1720210289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 E. CESAR CHAVEZ AVE.
Provider Second Line Business Mailing Address:
SUITE 3750
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90033-2424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-221-1302
Provider Business Mailing Address Fax Number:
323-221-1502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 E. CESAR CHAVEZ AVENUE
Provider Second Line Business Practice Location Address:
SUITE 3750
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90033-2424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-221-1302
Provider Business Practice Location Address Fax Number:
323-221-1502
Provider Enumeration Date:
08/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GRAVELY
Authorized Official First Name:
LANCE
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
323-221-1302

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  A87871 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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