Provider Demographics
NPI:1760820245
Name:LARA, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:LARA
Suffix:
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 1:1202 CORPUS CHRISTI ST
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78040-5353
Mailing Address - Country:US
Mailing Address - Phone:956-568-1572
Mailing Address - Fax:956-568-4720
Practice Address - Street 1:1202 CORPUS CHRISTI ST.
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040-5353
Practice Address - Country:US
Practice Address - Phone:956-568-1572
Practice Address - Fax:956-568-4720
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX6758930001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies