Healthcare Provider Details

I. General information

NPI: 1912458290
Provider Name (Legal Business Name): KENNETH LALAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N SEPULVEDA BLVD STE 210
MANHATTAN BEACH CA
90266-6849
US

IV. Provider business mailing address

40977 BANKHALL ST
LAKE ELSINORE CA
92532-1640
US

V. Phone/Fax

Practice location:
  • Phone: 310-379-2134
  • Fax:
Mailing address:
  • Phone: 213-905-8608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005230
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: