Healthcare Provider Details

I. General information

NPI: 1851667786
Provider Name (Legal Business Name): LARRY EDWARD GOTTFRIED RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 03/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E RIVER ST
ELYRIA OH
44035-5902
US

IV. Provider business mailing address

PO BOX 543
ALPHARETTA GA
30009-0543
US

V. Phone/Fax

Practice location:
  • Phone: 877-230-9617
  • Fax: 877-281-8770
Mailing address:
  • Phone: 678-983-4479
  • Fax: 404-751-5294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number205550
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: