Provider Demographics
NPI:1265712533
Name:GROSS, LARRY
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:GROSS
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 1:18880 ROAD 115
Mailing Address - Street 2:
Mailing Address - City:CECIL
Mailing Address - State:OH
Mailing Address - Zip Code:45821-9426
Mailing Address - Country:US
Mailing Address - Phone:419-439-2973
Mailing Address - Fax:
Practice Address - Street 1:18880 ROAD 115
Practice Address - Street 2:
Practice Address - City:CECIL
Practice Address - State:OH
Practice Address - Zip Code:45821-9426
Practice Address - Country:US
Practice Address - Phone:419-439-2973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH134002164W00000X
IN27066143A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse