Healthcare Provider Details

I. General information

NPI: 1326751496
Provider Name (Legal Business Name): LYDIA LATOUR ORNELAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LYDIA LATOUR

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 BIG BEND DR
PACIFICA CA
94044-3856
US

IV. Provider business mailing address

PO BOX 716
PACIFICA CA
94044-0716
US

V. Phone/Fax

Practice location:
  • Phone: 510-427-6568
  • Fax:
Mailing address:
  • Phone: 510-427-6568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: