=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609994342
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY S LEFORS D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 618 RAILROAD AVENUE SUITE A
-----------------------------------------------------
City | ZILLAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98953-0843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-829-5221
-----------------------------------------------------
Fax | 509-829-6411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 843
-----------------------------------------------------
City | ZILLAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98953-0843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-829-5221
-----------------------------------------------------
Fax | 509-829-6411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 00000767
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------