Provider Demographics
NPI:1750098281
Name:LARUE, LAVELLE II
Entity type:Individual
Prefix:MR
First Name:LAVELLE
Middle Name:
Last Name:LARUE
Suffix:II
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 1:4500 PARK GRANADA
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1663
Mailing Address - Country:US
Mailing Address - Phone:213-667-6944
Mailing Address - Fax:
Practice Address - Street 1:4500 PARK GRANADA
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-1663
Practice Address - Country:US
Practice Address - Phone:213-667-6944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8TVP754347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA88-1668629Medicaid