Provider Demographics
NPI:1811330053
Name:LARA, BERNARDA
Entity type:Individual
Prefix:MRS
First Name:BERNARDA
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58923 BUSINESS CENTER DRIVE
Mailing Address - Street 2:STE E
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284
Mailing Address - Country:US
Mailing Address - Phone:760-365-7209
Mailing Address - Fax:
Practice Address - Street 1:58923 BUSINESS CENTER DRIVE
Practice Address - Street 2:STE E
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284
Practice Address - Country:US
Practice Address - Phone:760-365-7209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program