Provider Demographics
NPI:1427129642
Name:FAZZIO, LORI RUBENSTEIN (PT)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:RUBENSTEIN
Last Name:FAZZIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 641428
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-6428
Mailing Address - Country:US
Mailing Address - Phone:310-401-6410
Mailing Address - Fax:
Practice Address - Street 1:11835 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 135E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-5001
Practice Address - Country:US
Practice Address - Phone:310-401-6410
Practice Address - Fax:310-312-3637
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 14694174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT14694AOtherMEDICARE PTAN
CAW16543OtherMEDICARE CORPORATION GROUP PTAN
CAW16543OtherMEDICARE CORPORATION GROUP PTAN