Provider Demographics
NPI:1821804881
Name:LACSON, REYNALDO BANTON JR
Entity type:Individual
Prefix:MR
First Name:REYNALDO
Middle Name:BANTON
Last Name:LACSON
Suffix:JR
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 1:2725 REDINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4668
Mailing Address - Country:US
Mailing Address - Phone:312-607-4672
Mailing Address - Fax:
Practice Address - Street 1:2725 REDINGTON ST
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-4668
Practice Address - Country:US
Practice Address - Phone:312-607-4672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296099225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist