Provider Demographics
NPI:1104824812
Name:LARA, JOSE (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:
Last Name:LARA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2735 W UNION HILLS DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-5033
Mailing Address - Country:US
Mailing Address - Phone:602-973-1630
Mailing Address - Fax:602-973-1667
Practice Address - Street 1:2735 W UNION HILLS DR
Practice Address - Street 2:SUITE 102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-5033
Practice Address - Country:US
Practice Address - Phone:602-973-1630
Practice Address - Fax:602-973-1667
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5303111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZWDBWZ01Medicare PIN
AZU52904Medicare UPIN