Healthcare Provider Details

I. General information

NPI: 1699907915
Provider Name (Legal Business Name): CARMEN L. LASTINE D.V.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 KOKOPELLI BLVD UNIT E
FRUITA CO
81521-8723
US

IV. Provider business mailing address

2076 VICTORIAN LN
GRAND JUNCTION CO
81505-8308
US

V. Phone/Fax

Practice location:
  • Phone: 970-858-4299
  • Fax:
Mailing address:
  • Phone: 970-201-5191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number3964
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: