Provider Demographics
NPI:1013199025
Name:DR. LARRY R. KINNICK P.C.
Entity Type:Organization
Organization Name:DR. LARRY R. KINNICK P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:KINNICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-596-0490
Mailing Address - Street 1:1910 OTTER POND CIR
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-9551
Mailing Address - Country:US
Mailing Address - Phone:970-596-0490
Mailing Address - Fax:
Practice Address - Street 1:1910 OTTER POND CIR
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-9551
Practice Address - Country:US
Practice Address - Phone:970-596-0490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4385150001Medicare NSC
CODG6936Medicare PIN
COC44853Medicare PIN