Healthcare Provider Details

I. General information

NPI: 1215357447
Provider Name (Legal Business Name): RENATO DELFINO LAZO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 04/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W VERDUGO AVE APT D
BURBANK CA
91506-2156
US

IV. Provider business mailing address

1900 WEST VERDUGO AVE. UNIT D
BURBANK CA
91506
US

V. Phone/Fax

Practice location:
  • Phone: 818-468-3371
  • Fax:
Mailing address:
  • Phone: 818-468-3371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: