Provider Demographics
NPI:1952630162
Name:LACANIENTA, LARRY MENDOZA
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:MENDOZA
Last Name:LACANIENTA
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 1:3827 S BUSHMILL DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-8943
Mailing Address - Country:US
Mailing Address - Phone:812-345-4643
Mailing Address - Fax:
Practice Address - Street 1:2055 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-3158
Practice Address - Country:US
Practice Address - Phone:765-342-3305
Practice Address - Fax:765-342-9575
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002937A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist