Provider Demographics
NPI:1326149394
Name:VINCENT, LARRY DEAN (DC)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:VINCENT
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 1:302 MEDICAL PLZ
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42345-1220
Mailing Address - Country:US
Mailing Address - Phone:270-338-3348
Mailing Address - Fax:270-338-3992
Practice Address - Street 1:302 MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1220
Practice Address - Country:US
Practice Address - Phone:270-338-3348
Practice Address - Fax:270-338-3992
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4554111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85000123Medicaid
KYU78630Medicare UPIN
KY6104601Medicare ID - Type UnspecifiedGREENVILLE OFFICE
KY85000123Medicaid