Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | DC4157 | TX |
Y | 111NR0400X | Rehabilitation Chiropractor | DC4157 | TX |
NPI | 1407922057 |
---|---|
Provider Name | Mr. Larry R Isbell |
First Address | Tyler, TX 75703-1004 |
Second Address | Tyler, TX 75703-1004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/11/2006 |
Last Update Date | 07/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
601544 | BCBS (01) | TX |
T13999 | (02) |