Healthcare Provider Details

I. General information

NPI: 1407542376
Provider Name (Legal Business Name): FREDERIC LASTAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4144 KENWAY AVE
VIEW PARK CA
90008-4810
US

IV. Provider business mailing address

4144 KENWAY AVE
VIEW PARK CA
90008-4810
US

V. Phone/Fax

Practice location:
  • Phone: 888-557-7217
  • Fax: 888-739-6925
Mailing address:
  • Phone: 888-557-7217
  • Fax: 888-739-6925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number133373
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: