Provider Demographics
NPI:1407895246
Name:TARTER, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:TARTER
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:PO BOX 757
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42345-0757
Mailing Address - Country:US
Mailing Address - Phone:270-338-2400
Mailing Address - Fax:270-338-2402
Practice Address - Street 1:224 HOPKINSVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1214
Practice Address - Country:US
Practice Address - Phone:270-338-2400
Practice Address - Fax:270-338-2402
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010460Medicaid
KY0714300001Medicare NSC
KY77010460Medicaid