Healthcare Provider Details

I. General information

NPI: 1053765636
Provider Name (Legal Business Name): LANCE SALCIDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 COVE RD
BROOKINGS OR
97415-2520
US

IV. Provider business mailing address

3587 HEATHROW WAY
MEDFORD OR
97504-4004
US

V. Phone/Fax

Practice location:
  • Phone: 541-469-0222
  • Fax: 541-469-0228
Mailing address:
  • Phone: 541-254-1137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: