Healthcare Provider Details

I. General information

NPI: 1710817028
Provider Name (Legal Business Name): LONNY KEITH DUE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26487 LAZY CREEK RD
MENIFEE CA
92586-3488
US

IV. Provider business mailing address

26487 LAZY CREEK RD
MENIFEE CA
92586-3488
US

V. Phone/Fax

Practice location:
  • Phone: 951-805-6076
  • Fax:
Mailing address:
  • Phone: 951-805-6076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number88167
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: