Healthcare Provider Details

I. General information

NPI: 1740768530
Provider Name (Legal Business Name): IRIS LARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25825 VERMONT AVE
HARBOR CITY CA
90710-3518
US

IV. Provider business mailing address

3595 SANTA FE AVE SPC 36
LONG BEACH CA
90810-4337
US

V. Phone/Fax

Practice location:
  • Phone: 310-257-6343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number29430
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: