1255664116 NPI number — BRIAN E. LARSON, D.C., P.C.

Table of content: (NPI 1255664116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255664116 NPI number — BRIAN E. LARSON, D.C., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIAN E. LARSON, D.C., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PREMIER CHIROPRACTIC & SPORTS INJURY CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255664116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
189 S BINKLEY ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
SOLDOTNA
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99669-8007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-262-0801
Provider Business Mailing Address Fax Number:
907-262-0860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
189 S BINKLEY ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SOLDOTNA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99669-8007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-262-0801
Provider Business Practice Location Address Fax Number:
907-262-0860
Provider Enumeration Date:
09/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LARSON
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
907-262-0801

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  396 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111NS0005X , with the licence number: 396 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CHG029 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: K163193 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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