Provider Demographics
NPI:1760651772
Name:MANDERNACK, LANCE (BS, RTT)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:MANDERNACK
Suffix:
Gender:M
Credentials:BS, RTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3371 GLENDALE BLVD
Mailing Address - Street 2:#186
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-1825
Mailing Address - Country:US
Mailing Address - Phone:323-666-5364
Mailing Address - Fax:
Practice Address - Street 1:3371 GLENDALE BLVD
Practice Address - Street 2:#186
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-1825
Practice Address - Country:US
Practice Address - Phone:323-666-5364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital