=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083617336
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY D HINSON R.P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2005
-----------------------------------------------------
Last Update Date | 11/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18661 OLD COAST HWY
-----------------------------------------------------
City | FORT BRAGG
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95437-8260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-964-5645
-----------------------------------------------------
Fax | 707-964-6213
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18661 OLD COAST HWY
-----------------------------------------------------
City | FORT BRAGG
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95437-8260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-964-5645
-----------------------------------------------------
Fax | 707-964-6213
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT6453
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------