Healthcare Provider Details

I. General information

NPI: 1861694168
Provider Name (Legal Business Name): ANTHONY J LARA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date: LARA ANTHONY J 2117 NAPA ST VALLEJO CA 94590 2201 TUOLUMNE ST VALLEJO CA 94589
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 TUOLUMNE ST
VALLEJO CA
94589-2524
US

IV. Provider business mailing address

2117 NAPA ST
VALLEJO CA
94590-3231
US

V. Phone/Fax

Practice location:
  • Phone: 707-558-1777
  • Fax: 707-558-1770
Mailing address:
  • Phone: 707-558-1777
  • Fax: 707-558-1770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: