Basic Information
| Provider Information | |||||||||
| NPI: | 1609141878 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANNING | ||||||||
| FirstName: | LARRY | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4488 334TH PL SE | ||||||||
| Address2: | |||||||||
| City: | FALL CITY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980245800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252811840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 670 NW GILMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980272444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254276562 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2012 | ||||||||
| LastUpdateDate: | 03/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA60256849 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.