MEDICARE: LANCE MANDERNACK BS, RTT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2865M2000X	Military General Acute Care Hospital

General Provider Information

NPI Number	:	1760651772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANCE MANDERNACK BS, RTT

Provider Business Mailing Address
First Line	:	3371 GLENDALE BLVD
Second Line	:	#186
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-1825
Country	:	US
Telephone Number	:	323-666-5364
Fax Number	:

Provider Business Practice Location Address
First Line	:	3371 GLENDALE BLVD
Second Line	:	#186
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-1825
Country	:	US
Telephone Number	:	323-666-5364
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2008
Last Update Date	:	02/22/2008

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