Provider Demographics
NPI:1508295288
Name:LARREYNAGA, MIGUEL A JR
Entity Type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:A
Last Name:LARREYNAGA
Suffix:JR
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 1:538 BROADHOLLOW RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3676
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:538 BROADHOLLOW RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3676
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:631-385-7795
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator