Healthcare Provider Details

I. General information

NPI: 1790828333
Provider Name (Legal Business Name): CARMEN LUCILA LARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 S E ST SUITE 250
SAN BERNARDINO CA
92408-2773
US

IV. Provider business mailing address

16207 GREENFIELD ST
MORENO VALLEY CA
92551-7239
US

V. Phone/Fax

Practice location:
  • Phone: 909-433-9300
  • Fax: 909-433-9308
Mailing address:
  • Phone: 909-433-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: