Provider Demographics
NPI:1720210289
Name:LANCE E.GRAVELY, M.D., INC.
Entity Type:Organization
Organization Name:LANCE E.GRAVELY, M.D., INC.
Other - Org Name:LANCE E. GRAVELY, M.D., INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:GRAVELY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-221-1302
Mailing Address - Street 1:1700 E. CESAR CHAVEZ AVE.
Mailing Address - Street 2:SUITE 3750
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2424
Mailing Address - Country:US
Mailing Address - Phone:323-221-1302
Mailing Address - Fax:323-221-1502
Practice Address - Street 1:1700 E. CESAR CHAVEZ AVENUE
Practice Address - Street 2:SUITE 3750
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2424
Practice Address - Country:US
Practice Address - Phone:323-221-1302
Practice Address - Fax:323-221-1502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87871207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI13702Medicare UPIN