Provider Demographics
NPI:1629479712
Name:MAYNARD, LARRY KEVIN
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:KEVIN
Last Name:MAYNARD
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 1:80 NE 758TH ST
Mailing Address - Street 2:
Mailing Address - City:OLD TOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32680-9678
Mailing Address - Country:US
Mailing Address - Phone:352-542-1635
Mailing Address - Fax:352-542-1634
Practice Address - Street 1:80 NE 758TH ST
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:FL
Practice Address - Zip Code:32680-9678
Practice Address - Country:US
Practice Address - Phone:352-542-1635
Practice Address - Fax:352-542-1634
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor