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General NPI Number Information
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NPI Number | 1063846764
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Entity Type | Individual
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Provider Name | BENJAMIN RAMON LARA LMSW
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Gender | Male
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Dates
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Enumeration Date | 08/29/2013
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Last Update Date | 08/29/2013
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Provider Practice Location Address
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Address Line | 9196 W BARNES DR
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City | BOISE
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State | ID
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Zip | 83709-1552
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Country | US
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Telephone | 208-433-0400
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Fax | 208-433-5271
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Provider Business Mailing Address
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Address Line | 5859 MILLWRIGHT AVE
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City | GARDEN CITY
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State | ID
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Zip | 83714-1665
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Country | US
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Telephone | 208-433-0400
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Fax | 208-433-5271
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 32322
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License Number State | ID
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