Provider Demographics
NPI:1629297015
Name:SIMMONS, ROBERT PAUL (LAC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:PAUL
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:PAUL
Other - Last Name:LUNA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:5350 WALDO PL
Mailing Address - Street 2:
Mailing Address - City:EAGLE ROCK
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1670
Mailing Address - Country:US
Mailing Address - Phone:323-630-9675
Mailing Address - Fax:
Practice Address - Street 1:34161 YUCAIPA BLVD
Practice Address - Street 2:#STE E
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-6109
Practice Address - Country:US
Practice Address - Phone:909-790-4811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2008-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11640171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist