1174620215 NPI number — LACI D HENDRICKS DC

Table of content: LACI D HENDRICKS DC (NPI 1174620215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174620215 NPI number — LACI D HENDRICKS DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKS
Provider First Name:
LACI
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

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:
1174620215
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2306 OAKWOOD AVE
Provider Second Line Business Mailing Address:
#210
Provider Business Mailing Address City Name:
VENICE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90291-4955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-408-2295
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 S PACIFIC COAST HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDONDO BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90277-5003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-316-4838
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2006

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:  6551 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 31044 , 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: C 605653 . This is a "UNITED AMERICAN INS CO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 001119290 . This is a "APWU" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0000605653 . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 001989501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0005101694 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00207317 . This is a "PALMETTO GBA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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