Provider Demographics
NPI:1740667872
Name:PERKINS, LAMONT
Entity type:Individual
Prefix:
First Name:LAMONT
Middle Name:
Last Name:PERKINS
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 1:4480 N 70TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-5405
Mailing Address - Country:US
Mailing Address - Phone:414-544-1044
Mailing Address - Fax:414-202-1840
Practice Address - Street 1:4480 N 70TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-5405
Practice Address - Country:US
Practice Address - Phone:414-544-1044
Practice Address - Fax:414-202-1840
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIP625-5247-3326-03172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver