Provider Demographics
NPI:1396298915
Name:LAVON M. GAINEY
Entity type:Organization
Organization Name:LAVON M. GAINEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:DE CARVALHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-398-2020
Mailing Address - Street 1:11265 ALUMNI WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-6685
Mailing Address - Country:US
Mailing Address - Phone:904-518-6090
Mailing Address - Fax:
Practice Address - Street 1:11265 ALUMNI WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-6685
Practice Address - Country:US
Practice Address - Phone:904-518-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH13303OtherMENTAL HEALTH LICENSURE #