Provider Demographics
NPI:1104064138
Name:CLEVELAND, LARRY (RD, LD, LMT)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:CLEVELAND
Suffix:
Gender:M
Credentials:RD, LD, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 S I-35 E STE 128
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-4943
Mailing Address - Country:US
Mailing Address - Phone:972-824-5011
Mailing Address - Fax:
Practice Address - Street 1:2430 S I-35 E STE 128
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-4943
Practice Address - Country:US
Practice Address - Phone:972-824-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06352133V00000X
TX847306133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00460PMedicare UPIN