Healthcare Provider Details

I. General information

NPI: 1952187718
Provider Name (Legal Business Name): VICTOR D LARA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2695 S 4TH ST FL 1
EL CENTRO CA
92243-6012
US

IV. Provider business mailing address

202 N 8TH ST
EL CENTRO CA
92243-2302
US

V. Phone/Fax

Practice location:
  • Phone: 442-265-7650
  • Fax:
Mailing address:
  • Phone: 442-265-1525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15295
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: