Basic Information
Provider Information | |||||||||
NPI: | 1114303997 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LARUE | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 251 JOHNSTON ST SE STE 300 | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | AL | ||||||||
PostalCode: | 356012515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563409708 | ||||||||
FaxNumber: | 2563409624 | ||||||||
Practice Location | |||||||||
Address1: | 1387 STATE HIGHWAY 160 | ||||||||
Address2: |   | ||||||||
City: | WARRIOR | ||||||||
State: | AL | ||||||||
PostalCode: | 351804437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2056476849 | ||||||||
FaxNumber: | 2056474574 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2015 | ||||||||
LastUpdateDate: | 08/04/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH7676 | AL | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 1003819608 | 01 | AL | GROUP NPI | OTHER | 529917620 | 05 | AL |   | MEDICAID |