Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175L00000X | Homeopath | BG06149 | CA |
NPI | 1457477515 |
---|---|
Provider Name | Olivia Lugo |
First Address | Modesto, CA 95350-0413 |
Second Address | Modesto, CA 95350-0149 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
175F00000X | CMT, BEAUTICIAN (01) | CA |