Healthcare Provider Details

I. General information

NPI: 1851068308
Provider Name (Legal Business Name): LARRY TOLINO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 08/24/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 GENERAL CROOK ST.
FORT APACHE AZ
85926
US

IV. Provider business mailing address

PO BOX 730
FORT APACHE AZ
85926
US

V. Phone/Fax

Practice location:
  • Phone: 928-338-1021
  • Fax: 928-338-1022
Mailing address:
  • Phone: 928-338-1021
  • Fax: 928-338-1022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: