Provider Demographics
NPI:1780319608
Name:LEBOUTON, ALBERT VINCENT IV (SRNA)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:VINCENT
Last Name:LEBOUTON
Suffix:IV
Gender:M
Credentials:SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 TELEGRAPH AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3239
Mailing Address - Country:US
Mailing Address - Phone:800-607-6377
Mailing Address - Fax:
Practice Address - Street 1:3100 TELEGRAPH AVE STE 350
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3239
Practice Address - Country:US
Practice Address - Phone:800-607-6377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-24
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program