Provider Demographics
NPI:1558905406
Name:LARA LOMELI, JEOVANNY I
Entity Type:Individual
Prefix:MR
First Name:JEOVANNY
Middle Name:
Last Name:LARA LOMELI
Suffix:I
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 1:3131 SANTA ANITA AVE STE 112B
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733-1369
Mailing Address - Country:US
Mailing Address - Phone:626-636-2370
Mailing Address - Fax:626-453-3431
Practice Address - Street 1:2307 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3119
Practice Address - Country:US
Practice Address - Phone:213-351-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1366551019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1366551019OtherSUBSTANCE USE COUNSELOR