Provider Demographics
NPI:1881066595
Name:GARCIA, LYDIA (MA)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:GARCIA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 ARIZONA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1509
Mailing Address - Country:US
Mailing Address - Phone:909-658-4759
Mailing Address - Fax:
Practice Address - Street 1:1327 ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1509
Practice Address - Country:US
Practice Address - Phone:909-658-4759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251T00000X251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization