Healthcare Provider Details

I. General information

NPI: 1760651772
Provider Name (Legal Business Name): LANCE MANDERNACK BS, RTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3371 GLENDALE BLVD #186
LOS ANGELES CA
90039-1825
US

IV. Provider business mailing address

3371 GLENDALE BLVD #186
LOS ANGELES CA
90039-1825
US

V. Phone/Fax

Practice location:
  • Phone: 323-666-5364
  • Fax:
Mailing address:
  • Phone: 323-666-5364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: