Provider Demographics
NPI:1235219353
Name:LARRUCEA, SAMUEL CREED (DPT, ECS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:CREED
Last Name:LARRUCEA
Suffix:
Gender:M
Credentials:DPT, ECS
Other - Prefix:
Other - First Name:CREED
Other - Middle Name:
Other - Last Name:LARRUCEA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT, ECS
Mailing Address - Street 1:2047 BLACKRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-1248
Mailing Address - Country:US
Mailing Address - Phone:916-212-6396
Mailing Address - Fax:
Practice Address - Street 1:2805 J ST STE 210
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-4307
Practice Address - Country:US
Practice Address - Phone:916-212-6396
Practice Address - Fax:916-588-4943
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEN 522251E1300X
CAPT 24966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical