Provider Demographics
NPI:1669481081
Name:LARRY JACOB DARR
Entity Type:Organization
Organization Name:LARRY JACOB DARR
Other - Org Name:DARR'S BOOTERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-472-7026
Mailing Address - Street 1:1033 RANDOLPH ST
Mailing Address - Street 2:SOUTHGATE PLAZA
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-5785
Mailing Address - Country:US
Mailing Address - Phone:336-472-7026
Mailing Address - Fax:336-472-7062
Practice Address - Street 1:1033 RANDOLPH ST
Practice Address - Street 2:SOUTHGATE PLAZA
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-5785
Practice Address - Country:US
Practice Address - Phone:336-472-7026
Practice Address - Fax:336-472-7062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========OtherTAX ID NUMBER
NC4727650001Medicare ID - Type UnspecifiedMEDICARE