Provider Demographics
NPI:1265010193
Name:MEDORS, LARA N
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:N
Last Name:MEDORS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:MEADOW VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95722-0786
Mailing Address - Country:US
Mailing Address - Phone:650-804-3645
Mailing Address - Fax:
Practice Address - Street 1:700 CROTHER RD
Practice Address - Street 2:
Practice Address - City:MEADOW VISTA
Practice Address - State:CA
Practice Address - Zip Code:95722-9396
Practice Address - Country:US
Practice Address - Phone:650-804-3645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty