MEDICARE: GILBERT LARNCE RAINWATER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver

General Provider Information

NPI Number	:	1356940878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GILBERT LARNCE RAINWATER

Provider Business Mailing Address
First Line	:	6987 JORDAN RD
Second Line	:
City	:	LEWISBURG
State	:	OH
Zip	:	45338-9751
Country	:	US
Telephone Number	:	937-248-1630
Fax Number	:

Provider Business Practice Location Address
First Line	:	6987 JORDAN RD
Second Line	:
City	:	LEWISBURG
State	:	OH
Zip	:	45338-9751
Country	:	US
Telephone Number	:	937-248-1630
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2020
Last Update Date	:	10/27/2020

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