Provider Demographics
NPI:1134261050
Name:KING, LARRY COOPER
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:COOPER
Last Name:KING
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 1:3520 OAKDALE RD STE. B
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357
Mailing Address - Country:US
Mailing Address - Phone:209-847-7775
Mailing Address - Fax:209-847-7728
Practice Address - Street 1:3520 OAKDALE RD. STE. B
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95357-0714
Practice Address - Country:US
Practice Address - Phone:209-847-7775
Practice Address - Fax:209-847-7728
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA3557237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA0035570Medicaid
CAHA3557OtherLICENCE #