Provider Demographics
NPI:1316362080
Name:HAZEN, LAWRENCE
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:HAZEN
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 1:1422 MONTEREY ST
Mailing Address - Street 2:SUITE C-102
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2944
Mailing Address - Country:US
Mailing Address - Phone:805-543-5100
Mailing Address - Fax:805-543-5106
Practice Address - Street 1:1422 MONTEREY ST
Practice Address - Street 2:SUITE C-102
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2944
Practice Address - Country:US
Practice Address - Phone:805-543-5100
Practice Address - Fax:805-543-5106
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13027225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist