Provider Demographics
NPI:1467697730
Name:MITCHELL, VERNON HARRELL (UNLICENSED)
Entity Type:Individual
Prefix:MR
First Name:VERNON
Middle Name:HARRELL
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:UNLICENSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-2118
Mailing Address - Country:US
Mailing Address - Phone:510-235-3172
Mailing Address - Fax:
Practice Address - Street 1:4244 WALL AVE
Practice Address - Street 2:4505 TAFT AVE
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-3452
Practice Address - Country:US
Practice Address - Phone:510-235-3172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680386415Other193200000X MULTI- SPECIALTY GROUP