1417197666 NPI number — LARRY CHARLES STEVENS, PH.D., P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417197666 NPI number — LARRY CHARLES STEVENS, PH.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY CHARLES STEVENS, PH.D., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417197666
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 N BEAVER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-3103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-779-3783
Provider Business Mailing Address Fax Number:
928-773-1150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 N BEAVER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86001-3103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-779-3783
Provider Business Practice Location Address Fax Number:
928-773-1150
Provider Enumeration Date:
03/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
STEVENS
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
928-779-3783

Provider Taxonomy Codes

  • Taxonomy code: 103TH0004X , with the licence number:  1177 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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