Provider Demographics
NPI:1588671192
Name:ZIEMBA, LARE (DC)
Entity Type:Individual
Prefix:DR
First Name:LARE
Middle Name:
Last Name:ZIEMBA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 NW PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8731
Mailing Address - Country:US
Mailing Address - Phone:772-337-3141
Mailing Address - Fax:772-336-1160
Practice Address - Street 1:433 NW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8731
Practice Address - Country:US
Practice Address - Phone:772-337-3141
Practice Address - Fax:772-336-1160
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCHOOO6248111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3803511-00Medicaid
FL22644Medicare PIN
FL3803511-00Medicaid