MEDICARE: LARRY D TICE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician	18565	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942213475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY D TICE MD

Provider Business Mailing Address
First Line	:	551 KOKOPELLI BLVD UNIT I
Second Line	:
City	:	FRUITA
State	:	CO
Zip	:	81521-6305
Country	:	US
Telephone Number	:	970-858-2580
Fax Number	:	970-858-3211

Provider Business Practice Location Address
First Line	:	551 KOKOPELLI BLVD
Second Line	:	SUITE I
City	:	FRUITA
State	:	CO
Zip	:	81521-6305
Country	:	US
Telephone Number	:	970-858-2580
Fax Number	:	970-858-3211

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	04/23/2014

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