Provider Demographics
NPI:1063667152
Name:LUCENT CHIROPRACTIC
Entity Type:Organization
Organization Name:LUCENT CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGE
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAZATIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:310-592-7095
Mailing Address - Street 1:11633 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6511
Mailing Address - Country:US
Mailing Address - Phone:310-592-7095
Mailing Address - Fax:310-826-9894
Practice Address - Street 1:11633 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 214
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6511
Practice Address - Country:US
Practice Address - Phone:310-592-7095
Practice Address - Fax:310-826-9894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30358305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0303580OtherBLUE SHIELD
CA1124212303OtherNPI FOR CHIROPRACTIC