Healthcare Provider Details

I. General information

NPI: 1003653353
Provider Name (Legal Business Name): ALEXANDER LACSON CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1385 SHAW AVE STE 102
CLOVIS CA
93612-3949
US

IV. Provider business mailing address

1385 SHAW AVE STE 102
CLOVIS CA
93612-3949
US

V. Phone/Fax

Practice location:
  • Phone: 718-551-2564
  • Fax:
Mailing address:
  • Phone: 718-551-2564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number96676
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: