Provider Demographics
NPI:1114455110
Name:LARES, RICHARD ROLAND (SA-C)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ROLAND
Last Name:LARES
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11239 BALLARD PEAK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-5495
Mailing Address - Country:US
Mailing Address - Phone:210-240-4373
Mailing Address - Fax:
Practice Address - Street 1:11212 STATE HIGHWAY 151
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4498
Practice Address - Country:US
Practice Address - Phone:210-703-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-02
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant