Provider Demographics
NPI:1558035972
Name:TANUWIDJAJA, LUCYANA
Entity Type:Individual
Prefix:
First Name:LUCYANA
Middle Name:
Last Name:TANUWIDJAJA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6948 S SYRACUSE CT
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-1230
Mailing Address - Country:US
Mailing Address - Phone:720-404-6249
Mailing Address - Fax:
Practice Address - Street 1:6948 S SYRACUSE CT
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-1230
Practice Address - Country:US
Practice Address - Phone:720-404-6249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility