Provider Demographics
NPI:1124363767
Name:LALONE, DEREK C (LMT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:C
Last Name:LALONE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 DIXON RD
Mailing Address - Street 2:
Mailing Address - City:MANNSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13661-4243
Mailing Address - Country:US
Mailing Address - Phone:315-465-7995
Mailing Address - Fax:
Practice Address - Street 1:711 BORDEN RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-3232
Practice Address - Country:US
Practice Address - Phone:716-668-8108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-09
Last Update Date:2012-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27026515225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist