Healthcare Provider Details

I. General information

NPI: 1457624884
Provider Name (Legal Business Name): KELLY LAZOR DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 CLOVER LN
ALISO VIEJO CA
92656-2982
US

IV. Provider business mailing address

33 CLOVER LN
ALISO VIEJO CA
92656-2982
US

V. Phone/Fax

Practice location:
  • Phone: 949-292-8824
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number38748
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: