Provider Demographics
NPI:1467791749
Name:DE LA VINA, LUCERO
Entity Type:Individual
Prefix:
First Name:LUCERO
Middle Name:
Last Name:DE LA VINA
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 1:2206 COPPER HILL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1648
Mailing Address - Country:US
Mailing Address - Phone:956-744-7070
Mailing Address - Fax:
Practice Address - Street 1:4301 N FEDERAL HWY
Practice Address - Street 2:SUITE 2 SOUTH
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-6519
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:954-342-0273
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist