Healthcare Provider Details

I. General information

NPI: 1972347334
Provider Name (Legal Business Name): JACK DE LARA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13100 STUDEBAKER RD
NORWALK CA
90650-2500
US

IV. Provider business mailing address

13100 STUDEBAKER RD
NORWALK CA
90650-2500
US

V. Phone/Fax

Practice location:
  • Phone: 855-464-2234
  • Fax: 562-929-2592
Mailing address:
  • Phone: 855-464-2234
  • Fax: 562-929-2592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95079088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: