Provider Demographics
NPI:1902220379
Name:LAVENDER, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LAVENDER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:DAVID
Other - Last Name:LAVENDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, ATC, LAT
Mailing Address - Street 1:1250 S MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-1370
Mailing Address - Country:US
Mailing Address - Phone:336-750-2597
Mailing Address - Fax:
Practice Address - Street 1:1250 S MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-1370
Practice Address - Country:US
Practice Address - Phone:336-750-2597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer