Healthcare Provider Details

I. General information

NPI: 1811179633
Provider Name (Legal Business Name): MR. LARRY EDWARD MCGILL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16500 PIERCE FERRY RD
DOLAN SPRINGS AZ
86441
US

IV. Provider business mailing address

16500 PIERCE FERRY RD
DOLAN SPRINGS AZ
86441
US

V. Phone/Fax

Practice location:
  • Phone: 928-767-3350
  • Fax: 928-767-4330
Mailing address:
  • Phone: 928-767-3350
  • Fax: 928-767-4330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: