Provider Demographics
NPI:1679027130
Name:LARA, CHRISTIAN EDUARDO (PTA26488)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:EDUARDO
Last Name:LARA
Suffix:
Gender:M
Credentials:PTA26488
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2859 W ALEUTS DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-3019
Mailing Address - Country:US
Mailing Address - Phone:352-364-7258
Mailing Address - Fax:
Practice Address - Street 1:700 SE 8TH AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4855
Practice Address - Country:US
Practice Address - Phone:352-795-8832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26488225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant