1114908910 NPI number — DR. LARS EVERT LUNDSTROM DC

Table of content: DR. LARS EVERT LUNDSTROM DC (NPI 1114908910)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114908910 NPI number — DR. LARS EVERT LUNDSTROM DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDSTROM
Provider First Name:
LARS
Provider Middle Name:
EVERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114908910
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9058 HAVASU ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VENTURA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93004-3037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-654-1432
Provider Business Mailing Address Fax Number:
805-654-1442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2686 JOHNSON DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
VENTURA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93003-7207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-654-1432
Provider Business Practice Location Address Fax Number:
805-654-1442
Provider Enumeration Date:
11/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  19200 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC0192000 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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