Provider Demographics
NPI:1437640448
Name:LANE, KEVIN LAMONT
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LAMONT
Last Name:LANE
Suffix:
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 1:7149 JENNINGS RD NE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-9431
Mailing Address - Country:US
Mailing Address - Phone:910-231-5770
Mailing Address - Fax:
Practice Address - Street 1:7149 JENNINGS RD NE
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-9431
Practice Address - Country:US
Practice Address - Phone:910-231-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC83-0638824305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC83-0638824Medicaid