Healthcare Provider Details

I. General information

NPI: 1235219353
Provider Name (Legal Business Name): SAMUEL CREED LARRUCEA DPT, ECS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CREED LARRUCEA DPT, ECS

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 J ST STE 210
SACRAMENTO CA
95816-4307
US

IV. Provider business mailing address

2047 BLACKRIDGE AVE
SACRAMENTO CA
95835-1248
US

V. Phone/Fax

Practice location:
  • Phone: 916-212-6396
  • Fax: 916-588-4943
Mailing address:
  • Phone: 916-212-6396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 24966
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License NumberEN 52
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: