Healthcare Provider Details

I. General information

NPI: 1104673383
Provider Name (Legal Business Name): STEPHANIE LAZCANO LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2024
Last Update Date: 05/04/2024
Certification Date: 05/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 W ERIE ST STE 100
CHICAGO IL
60654-3914
US

IV. Provider business mailing address

29W114 BARNES AVE
WEST CHICAGO IL
60185-3631
US

V. Phone/Fax

Practice location:
  • Phone: 312-877-5155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198001643
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: