MEDICARE: LARRY PITTMAN

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	224Z00000X	Occupational Therapy Assistant	TA2416	MS

General Provider Information

NPI Number	:	1396169058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY PITTMAN

Provider Business Mailing Address
First Line	:	PO BOX 817
Second Line	:
City	:	WEST POINT
State	:	MS
Zip	:	39773-0817
Country	:	US
Telephone Number	:	662-494-3011
Fax Number	:

Provider Business Practice Location Address
First Line	:	1122 N ESHMAN AVE
Second Line	:
City	:	WEST POINT
State	:	MS
Zip	:	39773-5436
Country	:	US
Telephone Number	:	662-494-6011
Fax Number	:

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

Provider Enumeration Date	:	02/14/2014
Last Update Date	:	02/14/2014

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