Healthcare Provider Details

I. General information

NPI: 1326532417
Provider Name (Legal Business Name): NICOLAS LANE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 BONNIE CLAIRE DR
WALNUT CA
91789-4185
US

IV. Provider business mailing address

4373 WHITNEY CT
CHINO CA
91710-3963
US

V. Phone/Fax

Practice location:
  • Phone: 909-554-0335
  • Fax:
Mailing address:
  • Phone: 909-554-0335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2081S0010X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: