Provider Demographics
NPI:1174620215
Name:HENDRICKS, LACI D (DC)
Entity type:Individual
Prefix:
First Name:LACI
Middle Name:D
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 OAKWOOD AVE
Mailing Address - Street 2:#210
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-4955
Mailing Address - Country:US
Mailing Address - Phone:310-408-2295
Mailing Address - Fax:
Practice Address - Street 1:1300 S PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5003
Practice Address - Country:US
Practice Address - Phone:310-316-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6551111N00000X
CA31044111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC 605653OtherUNITED AMERICAN INS CO
TX001119290OtherAPWU
TX0000605653OtherBCBS OF TEXAS
TX001989501Medicaid
TX0005101694OtherAETNA
TXP00207317OtherPALMETTO GBA
TX001119290OtherAPWU
TXU65525Medicare UPIN