Provider Demographics
NPI:1265619589
Name:DE LARA, JOHN ROCCO BORROMEO (PT)
Entity type:Individual
Prefix:
First Name:JOHN ROCCO
Middle Name:BORROMEO
Last Name:DE LARA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 TYLER CHRISTIAN DR
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-8927
Mailing Address - Country:US
Mailing Address - Phone:985-209-2511
Mailing Address - Fax:
Practice Address - Street 1:252 TYLER CHRISTIAN DR
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-8927
Practice Address - Country:US
Practice Address - Phone:985-209-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02594F225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist