Basic Information
| Provider Information | |||||||||
| NPI: | 1215323845 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CINICOLA | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | IV | ||||||||
| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 PROFESSIONAL BUILDING | ||||||||
| Address2: | 1265 WAYNE AVENUE, SUITE 308 | ||||||||
| City: | INDIANA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157013501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7248018095 | ||||||||
| FaxNumber: | 7248018147 | ||||||||
| Practice Location | |||||||||
| Address1: | 3215 N 5TH STREET HWY | ||||||||
| Address2: | UNIT #4 | ||||||||
| City: | READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196052450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845094235 | ||||||||
| FaxNumber: | 4847092754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | DAPT003925 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT024196 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3931225000 | 01 | PA | IBC | OTHER | 50132432 | 01 | PA | CAPITAL BC | OTHER | 3160699 | 01 | PA | HIGHMARK | OTHER | 103008201 | 05 | PA | MEDICAID |