Provider Information for 1063846764
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Mr. BENJAMIN RAMON LARA LMSW
Sex: Male
NPI: 1063846764
Last Updated: 2013-08-29
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1063846764 | ||||||||
| Enumeration Date | 2013-08-29 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | 5859 MILLWRIGHT AVE GARDEN CITY, ID 83714-1665 United States Phone: 208-433-0400 | Fax:208-433-5271 | ||||||||
| Primary Practice Address | 9196 W BARNES DR BOISE, ID 83709-1552 United States Phone: 208-433-0400 | Fax:208-433-5271 | ||||||||
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