Individual
LARRY D TICE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
551 KOKOPELLI BLVD, SUITE I, FRUITA, CO 81521-6305
(970) 858-2580
(970) 858-3211
Mailing address
551 KOKOPELLI BLVD UNIT I, FRUITA, CO 81521-6305
(970) 858-2580
(970) 858-3211
Taxonomy
Speciality
Code
Description
License number
State
207T00000X
Neurological Surgery Physician
Primary
18565
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01185651
—
CO
Enumeration date
08/14/2006
Last updated
04/23/2014
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