Healthcare Provider Details

I. General information

NPI: 1083130389
Provider Name (Legal Business Name): GINO C LAZARO DIRECTOR OF NURSING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23331 MALTBY PL
HARBOR CITY CA
90710-1134
US

IV. Provider business mailing address

23331 MALTBY PL
HARBOR CITY CA
90710
US

V. Phone/Fax

Practice location:
  • Phone: 310-486-5106
  • Fax: 424-263-4750
Mailing address:
  • Phone: 310-486-5106
  • Fax: 424-263-4750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number552043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: