1871887661 NPI number — ELITE MEDICAL, PLLC

Table of content: DR. STEVEN BRADLEY LARSEN DPM (NPI 1336249721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871887661 NPI number — ELITE MEDICAL, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE MEDICAL, PLLC
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:
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:
1871887661
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2484
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38803-2484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-205-4652
Provider Business Mailing Address Fax Number:
662-205-4651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2633 TRACELAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUPELO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38801-4238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-205-4652
Provider Business Practice Location Address Fax Number:
662-205-4651
Provider Enumeration Date:
06/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HAIRE
Authorized Official First Name:
ANNE
Authorized Official Middle Name:
DYE
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
662-205-4652

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  16935 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00126275 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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