Healthcare Provider Details

I. General information

NPI: 1508277906
Provider Name (Legal Business Name): KENDRA RENEE LARATTA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 NE 7TH ST
GRANTS PASS OR
97526-1303
US

IV. Provider business mailing address

4201 COYOTE CREEK RD
WOLF CREEK OR
97497-9609
US

V. Phone/Fax

Practice location:
  • Phone: 800-958-2588
  • Fax:
Mailing address:
  • Phone: 541-441-6302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number08903
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: