Healthcare Provider Details

I. General information

NPI: 1568840346
Provider Name (Legal Business Name): RICHARD JOSHUWA LAZALDE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22723 BAY AVE APT 118
MORENO VALLEY CA
92553-8637
US

IV. Provider business mailing address

22723 BAY AVE APT 118
MORENO VALLEY CA
92553-8637
US

V. Phone/Fax

Practice location:
  • Phone: 951-536-5894
  • Fax:
Mailing address:
  • Phone: 951-536-5894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: