Provider Demographics
NPI:1437796141
Name:TESSA LARUE DC LLC
Entity Type:Organization
Organization Name:TESSA LARUE DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TESSA
Authorized Official - Middle Name:MADLYN
Authorized Official - Last Name:LARUE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:440-941-8212
Mailing Address - Street 1:18624 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3248
Mailing Address - Country:US
Mailing Address - Phone:440-941-8212
Mailing Address - Fax:
Practice Address - Street 1:18624 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3248
Practice Address - Country:US
Practice Address - Phone:440-941-8212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty