Healthcare Provider Details

I. General information

NPI: 1427322668
Provider Name (Legal Business Name): JESUS JAVIER LARA PENA SAS-I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. JESUS J LARA

II. Dates (important events)

Enumeration Date: 03/06/2012
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 COLLEGE AVENUE
BAKERSFIELD CA
93305
US

IV. Provider business mailing address

PO BOX 1000
BAKERSFIELD CA
93302-1000
US

V. Phone/Fax

Practice location:
  • Phone: 661-868-8111
  • Fax: 661-868-8087
Mailing address:
  • Phone: 661-868-6600
  • Fax: 661-868-6666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRW6809
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: