Provider Demographics
NPI:1336559186
Name:TATE, LARRY (LDO)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:TATE
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 420
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-0420
Mailing Address - Country:US
Mailing Address - Phone:606-528-2833
Mailing Address - Fax:606-528-2862
Practice Address - Street 1:107 KENTUCKY STREET
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701
Practice Address - Country:US
Practice Address - Phone:606-528-2833
Practice Address - Fax:606-528-2862
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0567156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY52905676Medicaid