1225267206 NPI number — DENA LARSEN DPT

Table of content: DENA LARSEN DPT (NPI 1225267206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225267206 NPI number — DENA LARSEN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSEN
Provider First Name:
DENA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

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:
1225267206
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4851 AUTO CENTER WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREMERTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98312-4308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-627-7768
Provider Business Mailing Address Fax Number:
360-627-8003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 SW SEDGWICK RD
Provider Second Line Business Practice Location Address:
STE. 310
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98367-6447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-874-8009
Provider Business Practice Location Address Fax Number:
360-874-8010
Provider Enumeration Date:
07/10/2009

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT60095067 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PU60095046 . This is a "INTERIM PERMIT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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