Basic Information
Provider Information
NPI: 1003145715
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LACANLALE
FirstName: JOSHUA
MiddleName: N
NamePrefix:  
NameSuffix:  
Credential: P.T.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 32490
Address2:  
City: PHOENIX
State: AZ
PostalCode: 850642490
CountryCode: US
TelephoneNumber: 6022304478
FaxNumber: 6022309962
Practice Location
Address1: 3035 S ELLSWORTH RD
Address2: BLDG 4, #128
City: MESA
State: AZ
PostalCode: 852122160
CountryCode: US
TelephoneNumber: 4803576500
FaxNumber: 4803576515
Other Information
ProviderEnumerationDate: 12/09/2009
LastUpdateDate: 12/09/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2251X0800X8754AZY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic

No ID Information.


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