Provider Demographics
NPI:1366906059
Name:RASCON, LAILII
Entity type:Individual
Prefix:
First Name:LAILII
Middle Name:
Last Name:RASCON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 SANTA ANA AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2139
Mailing Address - Country:US
Mailing Address - Phone:323-377-3765
Mailing Address - Fax:
Practice Address - Street 1:2001 SANTA ANA AVE
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2139
Practice Address - Country:US
Practice Address - Phone:323-377-3765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74047225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty