Provider Demographics
NPI:1871513614
Name:LIBBEE, LARRY LEE (CO)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:LEE
Last Name:LIBBEE
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7735 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4135
Mailing Address - Country:US
Mailing Address - Phone:260-483-5219
Mailing Address - Fax:260-484-2291
Practice Address - Street 1:7735 W JEFFERSON BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4135
Practice Address - Country:US
Practice Address - Phone:260-483-5219
Practice Address - Fax:260-484-2291
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INCO004903222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist