Provider Demographics
NPI:1659366185
Name:KINNISON, LARRY DALE (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DALE
Last Name:KINNISON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:LARRY
Other - Middle Name:DALE
Other - Last Name:KINNISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-0878
Mailing Address - Country:US
Mailing Address - Phone:830-693-5502
Mailing Address - Fax:830-693-5503
Practice Address - Street 1:900 AVENUE J
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-5127
Practice Address - Country:US
Practice Address - Phone:830-693-5502
Practice Address - Fax:830-693-5503
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2252111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX350900118OtherRAILROAD MEDICARE
TX600118Medicare ID - Type Unspecified
TXT14199Medicare UPIN