Provider Demographics
NPI:1083617336
Name:HINSON, LARRY D (RPT)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:D
Last Name:HINSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18661 OLD COAST HWY
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-8260
Mailing Address - Country:US
Mailing Address - Phone:707-964-5645
Mailing Address - Fax:707-964-6213
Practice Address - Street 1:18661 OLD COAST HWY
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-8260
Practice Address - Country:US
Practice Address - Phone:707-964-5645
Practice Address - Fax:707-964-6213
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6453225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT6453OtherCA. STATE LICENSE NUMBER
CAPT0064530Medicaid
CAPT6453OtherCA. STATE LICENSE NUMBER
CAPT0064530Medicaid