Basic Information
| Provider Information | |||||||||
| NPI: | 1649522723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARRETT | ||||||||
| FirstName: | LC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2083 BUCKSKIN WAY | ||||||||
| Address2: | |||||||||
| City: | TURLOCK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953809484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2020 STANDIFORD AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953506529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097020139 | ||||||||
| FaxNumber: | 2097580825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2012 | ||||||||
| LastUpdateDate: | 11/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.