Provider Demographics
NPI:1346738911
Name:LIZARRAGA, MANUEL JOSE (SA-C)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:JOSE
Last Name:LIZARRAGA
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1274 N CRESCENT HEIGHTS BLVD APT 226
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-5061
Mailing Address - Country:US
Mailing Address - Phone:786-508-8559
Mailing Address - Fax:
Practice Address - Street 1:1274 N CRESCENT HEIGHTS BLVD APT 226
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5061
Practice Address - Country:US
Practice Address - Phone:786-508-8559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-28
Last Update Date:2018-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14-132246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant