Healthcare Provider Details

I. General information

NPI: 1083548630
Provider Name (Legal Business Name): SEBASTIAN RAFAEL LARA MATOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8382 BAYMEADOWS RD
JACKSONVILLE FL
32256-4447
US

IV. Provider business mailing address

4090 HODGES BLVD APT 3209
JACKSONVILLE FL
32224-4228
US

V. Phone/Fax

Practice location:
  • Phone: 904-755-0646
  • Fax:
Mailing address:
  • Phone: 787-565-0596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: