Provider Demographics
NPI:1114908910
Name:LUNDSTROM, LARS EVERT (DC)
Entity Type:Individual
Prefix:DR
First Name:LARS
Middle Name:EVERT
Last Name:LUNDSTROM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9058 HAVASU ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-3037
Mailing Address - Country:US
Mailing Address - Phone:805-654-1432
Mailing Address - Fax:805-654-1442
Practice Address - Street 1:2686 JOHNSON DR
Practice Address - Street 2:SUITE 104
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-7207
Practice Address - Country:US
Practice Address - Phone:805-654-1432
Practice Address - Fax:805-654-1442
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0192000Medicaid
CADC0192000Medicaid