Provider Demographics
NPI:1205124039
Name:BULLARD, LAVALLE DEPRICE
Entity type:Individual
Prefix:
First Name:LAVALLE
Middle Name:DEPRICE
Last Name:BULLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:OMAR
Other - Middle Name:CAMARA
Other - Last Name:MUHAMMAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:22058 GOLDENCHAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-6955
Mailing Address - Country:US
Mailing Address - Phone:909-720-2699
Mailing Address - Fax:
Practice Address - Street 1:13800 HEACOCK ST
Practice Address - Street 2:SUITE C236
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3339
Practice Address - Country:US
Practice Address - Phone:951-653-0819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator