Provider Demographics
NPI:1457687212
Name:TACKWOOD, LOLIS C
Entity Type:Individual
Prefix:MR
First Name:LOLIS
Middle Name:C
Last Name:TACKWOOD
Suffix:
Gender:M
Credentials:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2500 WILSHIRE BLVD
Mailing Address - Street 2:922
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-4303
Mailing Address - Country:US
Mailing Address - Phone:213-487-9800
Mailing Address - Fax:213-487-9801
Practice Address - Street 1:2500 WILSHIRE BLVD
Practice Address - Street 2:922
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4303
Practice Address - Country:US
Practice Address - Phone:213-487-9800
Practice Address - Fax:213-487-9801
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)