Provider Demographics
NPI:1205092038
Name:BARDACH, LAWRENCE ALAN (OTR / L)
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:ALAN
Last Name:BARDACH
Suffix:
Gender:M
Credentials:OTR / L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 FARROLL RD
Mailing Address - Street 2:UNIT E
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-2654
Mailing Address - Country:US
Mailing Address - Phone:805-481-7529
Mailing Address - Fax:805-481-7529
Practice Address - Street 1:750 FARROLL RD
Practice Address - Street 2:UNIT E
Practice Address - City:GROVER BEACH
Practice Address - State:CA
Practice Address - Zip Code:93433-2654
Practice Address - Country:US
Practice Address - Phone:805-481-7529
Practice Address - Fax:805-481-7529
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT4352174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist