Provider Demographics
NPI:1508310343
Name:LAURIE, ALLIE JR (BA)
Entity Type:Individual
Prefix:
First Name:ALLIE
Middle Name:
Last Name:LAURIE
Suffix:JR
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 16TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2715
Mailing Address - Country:US
Mailing Address - Phone:310-309-6001
Mailing Address - Fax:
Practice Address - Street 1:1453 16TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2715
Practice Address - Country:US
Practice Address - Phone:310-309-6001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program