Healthcare Provider Details

I. General information

NPI: 1376073387
Provider Name (Legal Business Name): ALEXANDRIA ALICIA LACAYO MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N GRAND AVE
WALNUT CA
91789-1341
US

IV. Provider business mailing address

755 E DATE ST APT A11
BREA CA
92821-6661
US

V. Phone/Fax

Practice location:
  • Phone: 925-628-7628
  • Fax:
Mailing address:
  • Phone:
  • 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: