Healthcare Provider Details

I. General information

NPI: 1245792332
Provider Name (Legal Business Name): LARIN TIMOTHY CLARK IDMT, LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 CURTISS RD STE 100
BARKSDALE AFB LA
71110-2425
US

IV. Provider business mailing address

243 CURTISS RD STE 100
BARKSDALE AFB LA
71110-2425
US

V. Phone/Fax

Practice location:
  • Phone: 318-456-6555
  • Fax:
Mailing address:
  • Phone: 318-456-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002105974
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: