Healthcare Provider Details

I. General information

NPI: 1336261569
Provider Name (Legal Business Name): MR. LARRY MCQUATER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 MEADOWBROOK RD
JACKSON MS
39206-5260
US

IV. Provider business mailing address

240 MEADOWBROOK RD
JACKSON MS
39206-5260
US

V. Phone/Fax

Practice location:
  • Phone: 601-713-3366
  • Fax: 601-713-3388
Mailing address:
  • Phone: 601-713-3366
  • Fax: 601-713-3388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00440848
Identifier TypeMEDICAID
Identifier StateMS
Identifier Issuer
# 2
IdentifierAPP13354101
Identifier TypeOTHER
Identifier StateMS
Identifier IssuerVGM -INSURANCE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: