Healthcare Provider Details

I. General information

NPI: 1679732143
Provider Name (Legal Business Name): LARRY W. PAYNE HEALTH SERVICES TECH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

599 TOMALES RD
PETALUMA CA
94952-5002
US

IV. Provider business mailing address

599 TOMALES RD
PETALUMA CA
94952-5002
US

V. Phone/Fax

Practice location:
  • Phone: 707-765-7275
  • Fax: 707-765-7495
Mailing address:
  • Phone: 707-765-7275
  • Fax: 707-765-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: