Healthcare Provider Details

I. General information

NPI: 1922649920
Provider Name (Legal Business Name): LAZARO MENA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 WILSON TER
GLENDALE CA
91206-4007
US

IV. Provider business mailing address

21617 TURMERIC CT
SAUGUS CA
91350-1665
US

V. Phone/Fax

Practice location:
  • Phone: 818-425-6527
  • Fax:
Mailing address:
  • Phone: 818-425-6527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number723556
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: