Provider Demographics
NPI:1952307654
Name:SUTHERLAND, LARRY VAUGHN (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:VAUGHN
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BLISSFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49228-1325
Mailing Address - Country:US
Mailing Address - Phone:517-486-3492
Mailing Address - Fax:517-486-5669
Practice Address - Street 1:120 E ADRIAN ST
Practice Address - Street 2:BOX D
Practice Address - City:BLISSFIELD
Practice Address - State:MI
Practice Address - Zip Code:49228-1254
Practice Address - Country:US
Practice Address - Phone:517-486-3008
Practice Address - Fax:517-486-5669
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILS004601111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI769311OtherFIRST HEALTH
MA04128OtherPARAMOUNT
MI769311OtherFIRST HEALTH
MA04128OtherPARAMOUNT