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NPI Code Detail

MEDICARE: MR. LARRY MENDOZA LACANIENTA

MEDICARE: MR. LARRY MENDOZA LACANIENTA
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
1225100000XPhysical Therapist05002937AIN

General Provider Information

NPI Number : 1952630162
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. LARRY MENDOZA LACANIENTA
Provider Business Mailing Address
First Line : 3827 S BUSHMILL DR
Second Line :
City : BLOOMINGTON
State : IN
Zip : 47403-8943
Country : US
Telephone Number : 812-345-4643
Fax Number :
Provider Business Practice Location Address
First Line : 2055 HERITAGE DR
Second Line :
City : MARTINSVILLE
State : IN
Zip : 46151-3158
Country : US
Telephone Number : 765-342-3305
Fax Number : 765-342-9575
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/17/2009
Last Update Date : 12/17/2009

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