Provider Demographics
NPI:1295814879
Name:NOVOTNY, LARRY LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:LEE
Last Name:NOVOTNY
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 1:614 HAWTHORNE ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-1661
Mailing Address - Country:US
Mailing Address - Phone:320-762-2309
Mailing Address - Fax:320-762-2300
Practice Address - Street 1:614 HAWTHORNE ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1661
Practice Address - Country:US
Practice Address - Phone:320-762-2309
Practice Address - Fax:320-762-2300
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1962111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN44-48002OtherMEDICA PIN #
MN4C812NOOtherBLUE CROSS BLUE SHIELD
MNT65934Medicare UPIN