Provider Demographics
NPI:1649481052
Name:RADKE, LARRY FREDRIC (DC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:FREDRIC
Last Name:RADKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 SW COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5254
Mailing Address - Country:US
Mailing Address - Phone:386-752-2252
Mailing Address - Fax:386-754-5088
Practice Address - Street 1:430 SW COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5254
Practice Address - Country:US
Practice Address - Phone:386-752-2252
Practice Address - Fax:386-754-5088
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0002067111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL89714OtherBLUECROSS BLUESHIELD PROV