Provider Demographics
NPI:1841392933
Name:BREAKFIELD, LAVAUGHAN (PT)
Entity Type:Individual
Prefix:
First Name:LAVAUGHAN
Middle Name:
Last Name:BREAKFIELD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 E PINE ST STE A
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5536
Mailing Address - Country:US
Mailing Address - Phone:209-463-5800
Mailing Address - Fax:209-463-5900
Practice Address - Street 1:840 S FAIRMONT AVE STE 5
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5105
Practice Address - Country:US
Practice Address - Phone:209-339-1690
Practice Address - Fax:209-339-1693
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT236020Medicare PIN
CABX651ZMedicare PIN