Provider Demographics
NPI:1699914168
Name:IMMENSCHUH, LARRY WILLIAM (RDLD)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WILLIAM
Last Name:IMMENSCHUH
Suffix:
Gender:M
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 NE INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-3438
Mailing Address - Country:US
Mailing Address - Phone:580-695-3213
Mailing Address - Fax:
Practice Address - Street 1:3009 N. W. WILSON STREET
Practice Address - Street 2:
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-9042
Practice Address - Country:US
Practice Address - Phone:580-458-2134
Practice Address - Fax:580-458-2314
Is Sole Proprietor?:No
Enumeration Date:2009-02-06
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK630133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered