Individual
LARRY R DIEDIKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
L.A.T.
Contact information
Practice address
508 MEDICAL CENTER BLVD, CONROE, TX 77304-2808
(936) 760-6631
Mailing address
13240 CREST DR, WILLIS, TX 77318-6611
(396) 228-5035
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
ATO170
TX
Other
Enumeration date
07/28/2006
Last updated
07/08/2007
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