Healthcare Provider Details

I. General information

NPI: 1114907649
Provider Name (Legal Business Name): LARRY JOE HALEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PLAZA PL
MINDEN LA
71055-3330
US

IV. Provider business mailing address

391 POST OAK LN
MINDEN LA
71055-8808
US

V. Phone/Fax

Practice location:
  • Phone: 318-377-2321
  • Fax: 318-371-3219
Mailing address:
  • Phone: 318-371-2725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number31805
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: