Healthcare Provider Details

I. General information

NPI: 1316468127
Provider Name (Legal Business Name): LAGS SPINE AND SPORTSCARE MEDICAL CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 NE 102ND AVE
PORTLAND OR
97220-4169
US

IV. Provider business mailing address

218 N I ST
LOMPOC CA
93436-0909
US

V. Phone/Fax

Practice location:
  • Phone: 503-477-8645
  • Fax: 503-208-2826
Mailing address:
  • Phone: 805-928-7361
  • Fax: 805-928-5742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: FRANCIS PETER LAGATTUTA
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 805-928-7361