MEDICARE: CHRISTIAN EDUARDO LARA PTA26488

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	225200000X	Physical Therapy Assistant	26488	FL

General Provider Information

NPI Number	:	1679027130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTIAN EDUARDO LARA PTA26488

Provider Business Mailing Address
First Line	:	2859 W ALEUTS DR
Second Line	:
City	:	BEVERLY HILLS
State	:	FL
Zip	:	34465-3019
Country	:	US
Telephone Number	:	352-364-7258
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 SE 8TH AVE
Second Line	:
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429-4855
Country	:	US
Telephone Number	:	352-795-8832
Fax Number	:

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

Provider Enumeration Date	:	08/12/2016
Last Update Date	:	08/12/2016

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