Provider Demographics
NPI:1508141623
Name:LARA, RODOLFO JR (RN)
Entity Type:Individual
Prefix:MR
First Name:RODOLFO
Middle Name:
Last Name:LARA
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11221 VAN BUREN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-1333
Mailing Address - Country:US
Mailing Address - Phone:323-755-1385
Mailing Address - Fax:
Practice Address - Street 1:11221 VAN BUREN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-1333
Practice Address - Country:US
Practice Address - Phone:323-755-1385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA600462163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health