MEDICARE: DR. GLADYS LARA DN

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	172P00000X	Naprapath
2	174400000X	Specialist	181.000406	IL
3	204C00000X	Sports Medicine (Neuromusculoskeletal Medicine) Physician	181.000406	IL
4	208100000X	Physical Medicine & Rehabilitation Physician	181.000406	IL
5	225700000X	Massage Therapist
6	172P00000X	Naprapath	181.000406	IL

General Provider Information

NPI Number	:	1568033629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLADYS LARA DN

Provider Business Mailing Address
First Line	:	4107 W BELMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-4617
Country	:	US
Telephone Number	:	773-710-9457
Fax Number	:

Provider Business Practice Location Address
First Line	:	4107 W BELMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-4617
Country	:	US
Telephone Number	:	773-710-9457
Fax Number	:

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

Provider Enumeration Date	:	07/08/2021
Last Update Date	:	10/06/2021

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