Provider Demographics
NPI:1578775318
Name:MANCUSO, LORI T (DC)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:T
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 MOHR AVE., SUITE K
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566
Mailing Address - Country:US
Mailing Address - Phone:925-484-3955
Mailing Address - Fax:925-484-3045
Practice Address - Street 1:4125 MOHR AVE., SUITE K
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566
Practice Address - Country:US
Practice Address - Phone:925-484-3955
Practice Address - Fax:925-484-3045
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24792111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC024792OtherBLUE CROSS BLUE SHIELD
CADC024792OtherBLUE CROSS BLUE SHIELD
CA24792Medicare UPIN