Basic Information
| Provider Information | |||||||||
| NPI: | 1952630162 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACANIENTA | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | MENDOZA | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3827 S BUSHMILL DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474038943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123454643 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2055 HERITAGE DR | ||||||||
| Address2: | |||||||||
| City: | MARTINSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461513158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653423305 | ||||||||
| FaxNumber: | 7653429575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2009 | ||||||||
| LastUpdateDate: | 12/17/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05002937A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.