Healthcare Provider Details

I. General information

NPI: 1912816240
Provider Name (Legal Business Name): LACEY FOGATA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 S MAIN ST STE 205
CORONA CA
92882-2533
US

IV. Provider business mailing address

4390 JURUPA AVE
RIVERSIDE CA
92506-1766
US

V. Phone/Fax

Practice location:
  • Phone: 951-475-1307
  • Fax:
Mailing address:
  • Phone: 951-742-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310996
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: