Provider Demographics
NPI:1396808945
Name:LAVARDERA, KRISTI
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:LAVARDERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 BLOOMFIELD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2504
Mailing Address - Country:US
Mailing Address - Phone:562-431-9511
Mailing Address - Fax:562-432-3301
Practice Address - Street 1:10801 BLOOMFIELD ST
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2504
Practice Address - Country:US
Practice Address - Phone:562-431-9511
Practice Address - Fax:562-432-3301
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30000OtherPT LICENSE