Provider Demographics
NPI:1518407063
Name:LICE CLINICS OF AMERICA WESTERN TERRITORIES LLC
Entity Type:Organization
Organization Name:LICE CLINICS OF AMERICA WESTERN TERRITORIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-620-2243
Mailing Address - Street 1:322 CERNON ST
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-4502
Mailing Address - Country:US
Mailing Address - Phone:855-500-5423
Mailing Address - Fax:
Practice Address - Street 1:322 CERNON ST
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-4502
Practice Address - Country:US
Practice Address - Phone:855-500-5423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty