Provider Demographics
NPI:1427489087
Name:LAVIN, BENNETT (DPT)
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:
Last Name:LAVIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6131
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:30141 ANTELOPE RD
Practice Address - Street 2:SUITE A
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-7001
Practice Address - Country:US
Practice Address - Phone:951-723-1866
Practice Address - Fax:951-723-1867
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40818225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA112199OtherMEDICARE PTAN