Provider Demographics
NPI:1114456167
Name:LARES, LUIS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:LARES
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 1ST ST NE APT 346
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-4793
Mailing Address - Country:US
Mailing Address - Phone:702-716-9701
Mailing Address - Fax:
Practice Address - Street 1:9141 ALAKING CT
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-5043
Practice Address - Country:US
Practice Address - Phone:301-499-4655
Practice Address - Fax:301-499-0902
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211115225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist