Provider Demographics
NPI:1558068213
Name:LARA, ALEX IVAN
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:IVAN
Last Name:LARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13527 CRAPE MYRTLE DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-4396
Mailing Address - Country:US
Mailing Address - Phone:951-421-5678
Mailing Address - Fax:951-421-5678
Practice Address - Street 1:13527 CRAPE MYRTLE DR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-4396
Practice Address - Country:US
Practice Address - Phone:951-421-5678
Practice Address - Fax:951-421-5678
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging