Provider Demographics
NPI:1467626648
Name:MINIX, LARRY L (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:MINIX
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 TAMARACK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-6984
Mailing Address - Country:US
Mailing Address - Phone:270-926-4933
Mailing Address - Fax:270-688-0627
Practice Address - Street 1:1115 TAMARACK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-6984
Practice Address - Country:US
Practice Address - Phone:270-926-4933
Practice Address - Fax:270-688-0627
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY0394156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY52903945Medicaid