Provider Demographics
NPI:1154949964
Name:LOS BANOS, LUKELA
Entity type:Individual
Prefix:
First Name:LUKELA
Middle Name:
Last Name:LOS BANOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14701 C ST S APT 61
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-7222
Mailing Address - Country:US
Mailing Address - Phone:808-779-1815
Mailing Address - Fax:
Practice Address - Street 1:35617 WA-507
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597
Practice Address - Country:US
Practice Address - Phone:808-779-1815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60756509225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist