Healthcare Provider Details

I. General information

NPI: 1669656419
Provider Name (Legal Business Name): LARRY J ASSALITA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 REGENT CT SUITE 200
STATE COLLEGE PA
16801-7966
US

IV. Provider business mailing address

110 REGENT CT SUITE 200
STATE COLLEGE PA
16801-7966
US

V. Phone/Fax

Practice location:
  • Phone: 814-238-0675
  • Fax: 814-238-8455
Mailing address:
  • Phone: 814-238-0675
  • Fax: 814-238-8455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberSC002410-L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberSC002410-L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0867765
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier862816801
Identifier TypeOTHER
Identifier State
Identifier IssuerTRICARE

VIII. Authorized Official

Name: DR. LARRY J ASSALITA
Title or Position: PROPRIETOR
Credential: DPM
Phone: 814-238-0675