Provider Demographics
NPI:1457098972
Name:GOMOLL, LARS
Entity Type:Individual
Prefix:
First Name:LARS
Middle Name:
Last Name:GOMOLL
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 1:4829 DIAMONDS PALM LOOP
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-7160
Mailing Address - Country:US
Mailing Address - Phone:305-773-6861
Mailing Address - Fax:
Practice Address - Street 1:414 E CHAPMAN RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-5779
Practice Address - Country:US
Practice Address - Phone:813-235-4006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27042225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant