Provider Demographics
NPI:1104840461
Name:LACE, JOHN WALTER (MD, FCCP)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALTER
Last Name:LACE
Suffix:
Gender:F
Credentials:MD, FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 LITTON DR STE 120
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5080
Mailing Address - Country:US
Mailing Address - Phone:530-477-7782
Mailing Address - Fax:530-477-7792
Practice Address - Street 1:140 LITTON DR STE 120
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5080
Practice Address - Country:US
Practice Address - Phone:530-477-7782
Practice Address - Fax:530-477-7792
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG085476174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G854760Medicaid
CAF31815Medicare UPIN
CA00G854760Medicaid