Provider Demographics
NPI:1639604705
Name:WEBBER, LODRICK
Entity type:Individual
Prefix:
First Name:LODRICK
Middle Name:
Last Name:WEBBER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9046 BORKEL PL
Mailing Address - Street 2:2ND FL
Mailing Address - City:QUEENS VLG
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1319
Mailing Address - Country:US
Mailing Address - Phone:718-506-5520
Mailing Address - Fax:
Practice Address - Street 1:9046 BORKEL PL
Practice Address - Street 2:2ND FL
Practice Address - City:QUEENS VLG
Practice Address - State:NY
Practice Address - Zip Code:11428-1319
Practice Address - Country:US
Practice Address - Phone:718-506-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328593164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse