Provider Demographics
NPI:1265932180
Name:LARCENA, LORD CHRISTOPHER BAGACINA
Entity type:Individual
Prefix:MR
First Name:LORD CHRISTOPHER
Middle Name:BAGACINA
Last Name:LARCENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 W GARFIELD AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2146
Mailing Address - Country:US
Mailing Address - Phone:818-296-5119
Mailing Address - Fax:
Practice Address - Street 1:212 W GARFIELD AVE APT 108
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2146
Practice Address - Country:US
Practice Address - Phone:818-296-5119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038246-1208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021Medicaid