Provider Demographics
NPI:1861114191
Name:TALBERT, LARRY C
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:C
Last Name:TALBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 DEVONPORT DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1552
Mailing Address - Country:US
Mailing Address - Phone:859-309-2240
Mailing Address - Fax:
Practice Address - Street 1:1365 DEVONPORT DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1552
Practice Address - Country:US
Practice Address - Phone:859-309-2240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1192511175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1192511Medicaid