Provider Demographics
NPI:1457477515
Name:LUGO, OLIVIA (CMT, BEAUTICIAN)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:LUGO
Suffix:
Gender:F
Credentials:CMT, BEAUTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 JANET CIR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-0413
Mailing Address - Country:US
Mailing Address - Phone:209-571-1940
Mailing Address - Fax:
Practice Address - Street 1:1901 STANDIFORD AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0149
Practice Address - Country:US
Practice Address - Phone:209-402-8211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABG06149175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA175F00000XOtherCMT, BEAUTICIAN