Healthcare Provider Details

I. General information

NPI: 1093773236
Provider Name (Legal Business Name): PETER M LIRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 S ANAHEIM BLVD SUITE G
ANAHEIM CA
92805-6218
US

IV. Provider business mailing address

1550 SO ANAHEIM BLVD SUITE G
ANAHEIM CA
92805-6218
US

V. Phone/Fax

Practice location:
  • Phone: 562-355-0279
  • Fax:
Mailing address:
  • Phone: 714-635-1401
  • Fax: 714-635-1422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO3156
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberCO0003156
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: