Provider Demographics
NPI:1619305356
Name:BRISCOE, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:BRISCOE
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 219672
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64121-9672
Mailing Address - Country:US
Mailing Address - Phone:816-628-4409
Mailing Address - Fax:816-407-2301
Practice Address - Street 1:305 S PLATTE CLAY WAY
Practice Address - Street 2:STE A
Practice Address - City:KEARNEY
Practice Address - State:MO
Practice Address - Zip Code:64060-8214
Practice Address - Country:US
Practice Address - Phone:816-628-4409
Practice Address - Fax:816-781-6973
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000173364225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist