Provider Demographics
NPI:1275854929
Name:MASON, ROBERT TYREE JR (LVN)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:TYREE
Last Name:MASON
Suffix:JR
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4263 OCEANSIDE BLVD UNIT 106-114
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-3479
Mailing Address - Country:US
Mailing Address - Phone:760-716-1047
Mailing Address - Fax:
Practice Address - Street 1:5703 SHETLAND CT
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92057-5720
Practice Address - Country:US
Practice Address - Phone:760-940-5279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 215679164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse