Healthcare Provider Details

I. General information

NPI: 1295486694
Provider Name (Legal Business Name): LACIE VIDOVICH RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15770 MISS ELLIE LN
LAKESIDE CA
92040-2600
US

IV. Provider business mailing address

15770 MISS ELLIE LN
LAKESIDE CA
92040-2600
US

V. Phone/Fax

Practice location:
  • Phone: 619-592-6680
  • Fax:
Mailing address:
  • Phone: 619-592-6680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number806895
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: