MEDICARE: ZACHERY R. LARUE PPS

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	101YS0200X	School Counselor	220208071	CA

General Provider Information

NPI Number	:	1386508810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACHERY R. LARUE PPS

Provider Business Mailing Address
First Line	:	7961 TAMARIND AVE
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92336-2753
Country	:	US
Telephone Number	:	909-357-5680
Fax Number	:	909-357-5680

Provider Business Practice Location Address
First Line	:	7961 TAMARIND AVE
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92336-2753
Country	:	US
Telephone Number	:	909-357-5680
Fax Number	:	909-357-5680

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

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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