Provider Demographics
NPI:1750821286
Name:BOTTOMLY, LUCETTE
Entity Type:Individual
Prefix:
First Name:LUCETTE
Middle Name:
Last Name:BOTTOMLY
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 1:1021 4TH ST
Mailing Address - Street 2:STE B
Mailing Address - City:TAFT
Mailing Address - State:CA
Mailing Address - Zip Code:93268-2433
Mailing Address - Country:US
Mailing Address - Phone:661-765-7025
Mailing Address - Fax:661-765-7045
Practice Address - Street 1:1021 4TH ST
Practice Address - Street 2:STE B
Practice Address - City:TAFT
Practice Address - State:CA
Practice Address - Zip Code:93268-2433
Practice Address - Country:US
Practice Address - Phone:661-765-7025
Practice Address - Fax:661-765-7045
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator