1295793875 NPI number — GREGORY LARSON MEDICAL TECHNOLOGIST

Table of content: GREGORY LARSON MEDICAL TECHNOLOGIST (NPI 1295793875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295793875 NPI number — GREGORY LARSON MEDICAL TECHNOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
GREGORY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MEDICAL TECHNOLOGIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1295793875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11101 COYHWY 17
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT LAKES
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-846-9901
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40520 CO HWY 34
Provider Second Line Business Practice Location Address:
WHITE EARTH HEALTH CENTER
Provider Business Practice Location Address City Name:
OGEMA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-983-4300
Provider Business Practice Location Address Fax Number:
218-983-6217
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 246Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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