Healthcare Provider Details

I. General information

NPI: 1700421120
Provider Name (Legal Business Name): JASON LACANLALE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 MOWRY AVE STE 115
FREMONT CA
94538-1766
US

IV. Provider business mailing address

6759 SIERRA CT STE A
DUBLIN CA
94568-2657
US

V. Phone/Fax

Practice location:
  • Phone: 510-790-3213
  • Fax: 510-790-3337
Mailing address:
  • Phone: 925-803-0530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT297570
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: