Provider Demographics
NPI:1124214697
Name:REED, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:REED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4518
Mailing Address - Country:US
Mailing Address - Phone:218-829-5380
Mailing Address - Fax:218-825-0972
Practice Address - Street 1:623 MADISON ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4518
Practice Address - Country:US
Practice Address - Phone:218-829-5380
Practice Address - Fax:218-825-0972
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN088H2REOtherBLUE CROSS BLUE SHIELD
6406206OtherMEDICA