Provider Demographics
NPI:1083896344
Name:SHANHONG LU
Entity type:Organization
Organization Name:SHANHONG LU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANHONG
Authorized Official - Middle Name:
Authorized Official - Last Name:LU
Authorized Official - Suffix:
Authorized Official - Credentials:MC
Authorized Official - Phone:530-926-1000
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-0218
Mailing Address - Country:US
Mailing Address - Phone:530-926-1000
Mailing Address - Fax:530-926-0375
Practice Address - Street 1:830 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2137
Practice Address - Country:US
Practice Address - Phone:530-926-1000
Practice Address - Fax:530-926-0375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61944174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29634ZMedicare PIN