Provider Demographics
NPI:1417216458
Name:FUJIWARA, LANCE MALO (MED, ATC)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:MALO
Last Name:FUJIWARA
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 LETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-2109
Mailing Address - Country:US
Mailing Address - Phone:540-570-0270
Mailing Address - Fax:540-464-7280
Practice Address - Street 1:307 LETCHER AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-2109
Practice Address - Country:US
Practice Address - Phone:540-570-0270
Practice Address - Fax:540-464-7280
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260002442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer