Provider Demographics
NPI:1528071099
Name:LAX, LARRY (CPO)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:LAX
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:MR
Other - First Name:ARYEH
Other - Middle Name:
Other - Last Name:LAX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPO
Mailing Address - Street 1:11301 WILSHIRE BLVD
Mailing Address - Street 2:BUILDING 304 PROSTHETICS
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90073-1003
Mailing Address - Country:US
Mailing Address - Phone:310-268-3875
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:BUILDING 304 PROSTHETICS
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-268-3875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224P00000X
VACPO879222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1528071099Medicare UPIN