Provider Demographics
NPI:1245403104
Name:THAO, LARA TRUE (MT)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:TRUE
Last Name:THAO
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 ARCADE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-1823
Mailing Address - Country:US
Mailing Address - Phone:651-771-2012
Mailing Address - Fax:651-771-8747
Practice Address - Street 1:1408 ARCADE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-1823
Practice Address - Country:US
Practice Address - Phone:651-771-2012
Practice Address - Fax:651-771-8747
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist