Provider Demographics
NPI:1588194906
Name:LARA J SPECIAL SERVICES CORPORATION
Entity Type:Organization
Organization Name:LARA J SPECIAL SERVICES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:JDANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-272-4898
Mailing Address - Street 1:273 LEVERETT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1508
Mailing Address - Country:US
Mailing Address - Phone:347-272-4898
Mailing Address - Fax:
Practice Address - Street 1:273 LEVERETT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-1508
Practice Address - Country:US
Practice Address - Phone:347-272-4898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1649689977Medicaid