Provider Demographics
NPI:1629876172
Name:ANDERSON, LARRY
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:ANDERSON
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 1:91 1ST
Mailing Address - Street 2:
Mailing Address - City:WEBSTER SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:26288
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:91 1ST
Practice Address - Street 2:
Practice Address - City:WEBSTER SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:26288
Practice Address - Country:US
Practice Address - Phone:304-618-1703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide