Provider Demographics
NPI:1811013014
Name:ST. JUNIUS, LIA S
Entity Type:Individual
Prefix:
First Name:LIA
Middle Name:S
Last Name:ST. JUNIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:PROF
Other - First Name:THE
Other - Middle Name:MOBILITY
Other - Last Name:STORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 821
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-0821
Mailing Address - Country:US
Mailing Address - Phone:562-989-6306
Mailing Address - Fax:888-432-1395
Practice Address - Street 1:505 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2830
Practice Address - Country:US
Practice Address - Phone:562-989-6306
Practice Address - Fax:888-432-1395
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0086788174400000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5148270001Medicare NSC