Provider Demographics
NPI:1073020210
Name:LAWANTORO, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LAWANTORO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26358 SAINT DAVID ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4178
Mailing Address - Country:US
Mailing Address - Phone:909-796-5258
Mailing Address - Fax:
Practice Address - Street 1:12000 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5174
Practice Address - Country:US
Practice Address - Phone:909-825-5221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15625225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA15625OtherBOARD OF OCCUPATIONAL THERAPY