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General NPI Number Information
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NPI Number | 1245244615
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Entity Type | Individual
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Provider Name | LARRY R DIEDIKER L.A.T.
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Gender | Male
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Dates
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Enumeration Date | 07/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 508 MEDICAL CENTER BLVD
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City | CONROE
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State | TX
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Zip | 77304-2808
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Country | US
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Telephone | 936-760-6631
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Fax |
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Provider Business Mailing Address
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Address Line | 13240 CREST DR
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City | WILLIS
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State | TX
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Zip | 77318-6611
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Country | US
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Telephone | 396-228-5035
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | ATO170
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License Number State | TX
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