Provider Demographics
NPI:1033267521
Name:MULLIS, LARRY JR (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:MULLIS
Suffix:JR
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2395
Mailing Address - Country:US
Mailing Address - Phone:478-452-6200
Mailing Address - Fax:478-452-6212
Practice Address - Street 1:1203 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2395
Practice Address - Country:US
Practice Address - Phone:478-452-6200
Practice Address - Fax:478-452-6212
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0005952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer