Provider Demographics
NPI:1518452994
Name:LOVE, LARRY BRANDONN (MS, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:BRANDONN
Last Name:LOVE
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 E OGDEN AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-1267
Mailing Address - Country:US
Mailing Address - Phone:708-218-7393
Mailing Address - Fax:
Practice Address - Street 1:350 E OGDEN AVE STE 104
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1267
Practice Address - Country:US
Practice Address - Phone:708-218-7393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer