MEDICARE: NANCY GALVAN LARA BA

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1699327775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY GALVAN LARA BA

Provider Business Mailing Address
First Line	:	881 W HAMILTON AVE
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-3813
Country	:	US
Telephone Number	:	760-460-6291
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 S IMPERIAL AVE
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-3149
Country	:	US
Telephone Number	:	760-679-0540
Fax Number	:

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

Provider Enumeration Date	:	07/10/2019
Last Update Date	:	07/10/2019

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