Provider Demographics
NPI:1346426954
Name:LAURENCE OF OAKLAND
Entity Type:Organization
Organization Name:LAURENCE OF OAKLAND
Other - Org Name:LAURENCE ORTHOPEDIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:510-658-2062
Mailing Address - Street 1:6001 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1310
Mailing Address - Country:US
Mailing Address - Phone:510-658-2062
Mailing Address - Fax:510-652-7779
Practice Address - Street 1:2190 MERIDIAN PARK BLVD STE E
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5715
Practice Address - Country:US
Practice Address - Phone:925-827-2062
Practice Address - Fax:925-827-2503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGFC000120Medicaid
CA0023321002Medicare NSC