Healthcare Provider Details

I. General information

NPI: 1770558447
Provider Name (Legal Business Name): CARLOS MANRIQUE DE LARA MDPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2518 W TRENTON RD
EDINBURG TX
78539-8070
US

IV. Provider business mailing address

2518 W TRENTON RD
EDINBURG TX
78539-8070
US

V. Phone/Fax

Practice location:
  • Phone: 956-661-9000
  • Fax: 956-686-7833
Mailing address:
  • Phone: 956-661-9000
  • Fax: 956-686-7833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CARLOS MANRIQUE DE LARA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 956-661-9000