Provider Demographics
NPI:1104457977
Name:LARA HEALTH AND WELLNESS CENTER LLC
Entity type:Organization
Organization Name:LARA HEALTH AND WELLNESS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YONAIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-415-2982
Mailing Address - Street 1:3105 W WATERS AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3105 W WATERS AVE STE 105
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2846
Practice Address - Country:US
Practice Address - Phone:813-443-0705
Practice Address - Fax:813-415-2982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-30
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)