Healthcare Provider Details

I. General information

NPI: 1003399106
Provider Name (Legal Business Name): LARRY BESONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 09/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22285 ROUNDUP DR
WALNUT CA
91789
US

IV. Provider business mailing address

22285 ROUNDUP DR
WALNUT CA
91789-1487
US

V. Phone/Fax

Practice location:
  • Phone: 909-973-7617
  • Fax:
Mailing address:
  • Phone: 909-973-7617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number12035
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: