Healthcare Provider Details

I. General information

NPI: 1033352018
Provider Name (Legal Business Name): TRINA LOUISE LAZAREK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 ORISKANY BLVD
WHITESBORO NY
13492-1317
US

IV. Provider business mailing address

34 ORISKANY BLVD
WHITESBORO NY
13492-1317
US

V. Phone/Fax

Practice location:
  • Phone: 315-768-8521
  • Fax: 315-768-7882
Mailing address:
  • Phone: 315-768-8521
  • Fax: 315-768-7882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number021014
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: