=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841448701
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES R LAROSE DPM A PROFESSIONAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2008
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1060 N 13TH AVENUE
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-3785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-985-2555
-----------------------------------------------------
Fax | 909-985-0068
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1060 N 13TH AVENUE
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-3785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-985-2555
-----------------------------------------------------
Fax | 909-985-0068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAMES R LAROSE
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 909-985-2555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------