Provider Demographics
NPI:1376100560
Name:DEMIANCZUK, LUCIANO
Entity Type:Individual
Prefix:
First Name:LUCIANO
Middle Name:
Last Name:DEMIANCZUK
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 1:15149 VICTORY BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-1736
Mailing Address - Country:US
Mailing Address - Phone:747-238-8288
Mailing Address - Fax:
Practice Address - Street 1:18111 NORDHOFF ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91330-0001
Practice Address - Country:US
Practice Address - Phone:818-667-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
22OtherRESPIRATORY, DEVELOPMENTAL, REHABILITATIVE, AND RESPIRATIVE SERVICE PROVIDER