Healthcare Provider Details

I. General information

NPI: 1619192705
Provider Name (Legal Business Name): LARRY ALTON DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E STATE ST
MONTROSE MI
48457-9144
US

IV. Provider business mailing address

190 E STATE ST
MONTROSE MI
48457-9144
US

V. Phone/Fax

Practice location:
  • Phone: 810-639-2056
  • Fax:
Mailing address:
  • Phone: 810-639-2056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101007136
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704164104
License Number StateMI

VIII. Authorized Official

Name: CATHY HITCHCOCK
Title or Position: OFFICE MANAGER
Credential:
Phone: 810-639-2056