Provider Demographics
NPI:1790388718
Name:UNDERDUE, LARRY EARL
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:EARL
Last Name:UNDERDUE
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 1:420 E MAIN AVE APT 1011
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4069
Mailing Address - Country:US
Mailing Address - Phone:701-204-1642
Mailing Address - Fax:
Practice Address - Street 1:420 E MAIN AVE APT 1011
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4069
Practice Address - Country:US
Practice Address - Phone:701-204-1642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14784913747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant