Provider Demographics
NPI:1780352443
Name:KESHISHIAN, LALA
Entity type:Individual
Prefix:
First Name:LALA
Middle Name:
Last Name:KESHISHIAN
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 1:1845 BUSINESS CENTER DR STE 127
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3434
Mailing Address - Country:US
Mailing Address - Phone:818-424-6464
Mailing Address - Fax:909-890-4393
Practice Address - Street 1:10470 FOOTHILL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3754
Practice Address - Country:US
Practice Address - Phone:909-948-0411
Practice Address - Fax:909-948-0511
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300825225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist