Healthcare Provider Details

I. General information

NPI: 1124229786
Provider Name (Legal Business Name): LARA V CARBALLO RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. LARA BOUFFARD

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2739 UPPER PARK RD
ORLANDO FL
32814-6148
US

IV. Provider business mailing address

2739 UPPER PARK RD
ORLANDO FL
32814-6148
US

V. Phone/Fax

Practice location:
  • Phone: 407-443-9696
  • Fax: 407-754-2624
Mailing address:
  • Phone: 407-443-9696
  • Fax: 407-754-2624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT13675
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: