Provider Demographics
NPI:1720806169
Name:LAUDERMILL, REGINALD JEROME I
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:JEROME
Last Name:LAUDERMILL
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E MANCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1910
Mailing Address - Country:US
Mailing Address - Phone:424-331-9268
Mailing Address - Fax:
Practice Address - Street 1:650 E MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1910
Practice Address - Country:US
Practice Address - Phone:424-331-9268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA841948112405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional