Provider Demographics
NPI:1801010517
Name:LOVELL, PHYLLIS DIANE (LAC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:DIANE
Last Name:LOVELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3440
Mailing Address - Country:US
Mailing Address - Phone:951-683-1694
Mailing Address - Fax:951-683-1689
Practice Address - Street 1:4045 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3440
Practice Address - Country:US
Practice Address - Phone:951-683-1694
Practice Address - Fax:951-683-1689
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 3085171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist