Provider Demographics
NPI:1497913719
Name:CLAWSON, LANCE R (CPO)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:R
Last Name:CLAWSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1926
Mailing Address - Country:US
Mailing Address - Phone:909-621-1180
Mailing Address - Fax:909-624-1650
Practice Address - Street 1:320 E BONITA AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1926
Practice Address - Country:US
Practice Address - Phone:909-621-1180
Practice Address - Fax:909-624-1650
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO01251222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000770Medicaid
CAGXC000770Medicaid