Provider Demographics
NPI:1568925055
Name:PRIEST, LARA ANNE
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:ANNE
Last Name:PRIEST
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 1:302 W GRAND AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-5108
Mailing Address - Country:US
Mailing Address - Phone:310-414-9595
Mailing Address - Fax:
Practice Address - Street 1:302 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3700
Practice Address - Country:US
Practice Address - Phone:310-414-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAUNKNOWN-STUDENT152W00000X
CA34422TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist