Provider Demographics
NPI:1225031511
Name:MADDALENA, LARRY (DC)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:MADDALENA
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 1:1732 PALMA DR
Mailing Address - Street 2:STE 104
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-5796
Mailing Address - Country:US
Mailing Address - Phone:805-642-6565
Mailing Address - Fax:805-642-6524
Practice Address - Street 1:1732 PALMA DR
Practice Address - Street 2:STE 104
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5796
Practice Address - Country:US
Practice Address - Phone:805-642-6565
Practice Address - Fax:805-642-6524
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24826111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0248260Medicaid
CAW16398Medicare PIN
CADC0248260Medicaid