1477236347 NPI number — DR. PATRICK LACKMANN TRAYNOR RD

Table of content: DR. PATRICK LACKMANN TRAYNOR RD (NPI 1477236347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477236347 NPI number — DR. PATRICK LACKMANN TRAYNOR RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRAYNOR
Provider First Name:
PATRICK
Provider Middle Name:
LACKMANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
RD
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:
1477236347
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
671 RIVER RANCH ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARKLEEVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-653-3471
Provider Business Mailing Address Fax Number:
949-269-0134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3079 HARRISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH LAKE TAHOE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-653-3471
Provider Business Practice Location Address Fax Number:
949-269-0134
Provider Enumeration Date:
08/08/2023

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: 133V00000X , with the licence number:  86082088 , 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)





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