Basic Information
| Provider Information | |||||||||
| NPI: | 1700421120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACANLALE | ||||||||
| FirstName: | JASON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6759 SIERRA CT | ||||||||
| Address2: | STE A | ||||||||
| City: | DUBLIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945682657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9258030530 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1895 MOWRY AVE STE 115 | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945381766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107903213 | ||||||||
| FaxNumber: | 5107903337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2019 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT297570 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT297570 | 01 | CA | LICENSE | OTHER |