Active NPI
Larry R Diediker, L.A.T.
- Athletic Trainer
- Conroe, TX
National Provider Identifier
1245244615
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- ATO170
- Practice address
- 508 Medical Center Blvd
Conroe, TX 77304-2808 - Phone
- (936) 760-6631
- NPI assigned
- Jul 28, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | ATO170 | TX | Primary |
Addresses
Primary practice location
508 Medical Center Blvd
Conroe, TX 77304-2808
Mailing address
13240 Crest Dr
Willis, TX 77318-6611
Phone (396) 228-5035
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| ATO170 | TX | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1154044800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1245244615",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "13240 CREST DR",
"city": "WILLIS",
"state": "TX",
"postal_code": "773186611",
"telephone_number": "396-228-5035"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "508 MEDICAL CENTER BLVD",
"city": "CONROE",
"state": "TX",
"postal_code": "773042808",
"telephone_number": "936-760-6631"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DIEDIKER",
"first_name": "LARRY",
"middle_name": "R",
"credential": "L.A.T.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-07-28",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "TX",
"license": "ATO170",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Conroe, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.