Provider Demographics
NPI:1063506160
Name:PROVENZANO, LORRAINE ANN (DC)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:ANN
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81709 DOCTOR CARREON BLVD STE A5
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5509
Mailing Address - Country:US
Mailing Address - Phone:760-342-2264
Mailing Address - Fax:760-342-4370
Practice Address - Street 1:81709 DOCTOR CARREON BLVD STE A5
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5509
Practice Address - Country:US
Practice Address - Phone:760-342-2264
Practice Address - Fax:760-342-4370
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16144111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0161440OtherBLUE SHIELD PROVIDER #
CADC0161440Medicare PIN
CAT06041Medicare UPIN