Provider Demographics
NPI:1093840407
Name:LARSEN DUNNICLIFF PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:LARSEN DUNNICLIFF PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:K
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:209-473-1138
Mailing Address - Street 1:2087 GRAND CANAL BLVD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6651
Mailing Address - Country:US
Mailing Address - Phone:209-473-1138
Mailing Address - Fax:209-473-1891
Practice Address - Street 1:2087 GRAND CANAL BLVD
Practice Address - Street 2:SUITE 17
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6651
Practice Address - Country:US
Practice Address - Phone:209-473-1138
Practice Address - Fax:209-473-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT66770174400000X
CAPT86420174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA650011088OtherRAILROAD MEDICARE
CA650008773OtherRAILROAD MEDICARE
CA650011088OtherRAILROAD MEDICARE
CA=========OtherTAX ID
CA00PT86420Medicare ID - Type Unspecified