Provider Demographics
NPI:1083627400
Name:BRYANT, LARRY EDWARD (DC)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:EDWARD
Last Name:BRYANT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 CALDER ST
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70053-5637
Mailing Address - Country:US
Mailing Address - Phone:504-361-3994
Mailing Address - Fax:504-364-1467
Practice Address - Street 1:1400 CALDER ST
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-5637
Practice Address - Country:US
Practice Address - Phone:504-361-3994
Practice Address - Fax:504-364-1467
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA282111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1938777Medicaid
LA20144OtherBLUE CROSS
LA20144OtherBLUE CROSS