Healthcare Provider Details

I. General information

NPI: 1538376249
Provider Name (Legal Business Name): TOLUCA LAKE MEDICAL MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10112 RIVERSIDE DR
TOLUCA LAKE CA
91602-2518
US

IV. Provider business mailing address

10112 RIVERSIDE DR
TOLUCA LAKE CA
91602-2518
US

V. Phone/Fax

Practice location:
  • Phone: 818-506-4558
  • Fax: 818-506-1739
Mailing address:
  • Phone: 818-506-4558
  • Fax: 818-506-1739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: MRS. DENA K. LAROSA
Title or Position: OFFICE MANAGER
Credential: OFFICE MANAGER
Phone: 818-506-4558