Provider Demographics
NPI:1952893315
Name:NYCUM, LARRY DEAN SR
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:NYCUM
Suffix:SR
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 1:5918 COWPASTURE RIVER HWY
Mailing Address - Street 2:
Mailing Address - City:MILLBORO
Mailing Address - State:VA
Mailing Address - Zip Code:24460-2490
Mailing Address - Country:US
Mailing Address - Phone:540-460-0869
Mailing Address - Fax:
Practice Address - Street 1:5918 COWPASTURE RIVER HWY
Practice Address - Street 2:
Practice Address - City:MILLBORO
Practice Address - State:VA
Practice Address - Zip Code:24460-2490
Practice Address - Country:US
Practice Address - Phone:540-460-0869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle