Provider Demographics
NPI:1386690915
Name:LAGRELIUS, THOMAS
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:LAGRELIUS
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 1:23451 MADISON ST
Mailing Address - Street 2:140
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4763
Mailing Address - Country:US
Mailing Address - Phone:310-378-6208
Mailing Address - Fax:310-378-2564
Practice Address - Street 1:23451 MADISON ST
Practice Address - Street 2:140
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4763
Practice Address - Country:US
Practice Address - Phone:310-378-6208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG022952OtherMEDICAL BOARD OF CA
CAA41788Medicare UPIN
CAG22952Medicare ID - Type Unspecified