Provider Demographics
NPI:1457682551
Name:ISAKOV, LANCE (MAC LAC,)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:ISAKOV
Suffix:
Gender:M
Credentials:MAC LAC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 BLOOMINGDALE AVENUE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087
Mailing Address - Country:US
Mailing Address - Phone:610-203-3747
Mailing Address - Fax:
Practice Address - Street 1:124 BLOOMINGDALE AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-3929
Practice Address - Country:US
Practice Address - Phone:610-203-3747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAKO000531171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist