Provider Demographics
NPI:1427409929
Name:LARRY FOREMAN, DO
Entity type:Organization
Organization Name:LARRY FOREMAN, DO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:FOREMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:805-459-8917
Mailing Address - Street 1:1945 CORBETT HIGHLANDS PL
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-4933
Mailing Address - Country:US
Mailing Address - Phone:805-459-8917
Mailing Address - Fax:
Practice Address - Street 1:345 S HALCYON RD
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3817
Practice Address - Country:US
Practice Address - Phone:805-459-8917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5055207PH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative MedicineGroup - Single Specialty