Provider Demographics
NPI:1962585331
Name:OGILVIE, LARRY M (LMT)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:M
Last Name:OGILVIE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961687 GATEWAY BLVD
Mailing Address - Street 2:SUITE 201C
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-9157
Mailing Address - Country:US
Mailing Address - Phone:904-491-4980
Mailing Address - Fax:
Practice Address - Street 1:961687 GATEWAY BLVD
Practice Address - Street 2:SUITE 201C
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-9157
Practice Address - Country:US
Practice Address - Phone:904-491-4980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA41179225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist