Healthcare Provider Details

I. General information

NPI: 1962672717
Provider Name (Legal Business Name): MR. LARRY SPECK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 M ST JAIL MEDICAL SERVICES, 2ND FLOOR
FRESNO CA
93721-1805
US

IV. Provider business mailing address

1225 M ST JAIL MEDICAL SERVICES, 2ND FLOOR
FRESNO CA
93721-1805
US

V. Phone/Fax

Practice location:
  • Phone: 559-442-2404
  • Fax: 559-442-5277
Mailing address:
  • Phone: 559-442-2404
  • Fax: 559-442-5277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number21268
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: