MEDICARE: NOEL DELA ROSA LARA NURSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	041 300897	IL

General Provider Information

NPI Number	:	1316482268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NOEL DELA ROSA LARA NURSE

Provider Business Mailing Address
First Line	:	430 E NERGE RD
Second Line	:
City	:	ROSELLE
State	:	IL
Zip	:	60172-4917
Country	:	US
Telephone Number	:	224-402-1330
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 16TH ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80202-5117
Country	:	US
Telephone Number	:	303-405-2100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2017
Last Update Date	:	01/02/2017

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