Provider Demographics
NPI:1902086416
Name:LARISON, TOMMY CLYDE (DC)
Entity Type:Individual
Prefix:DR
First Name:TOMMY
Middle Name:CLYDE
Last Name:LARISON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 SANGRE DE CRISTO
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9525
Mailing Address - Country:US
Mailing Address - Phone:505-300-6390
Mailing Address - Fax:
Practice Address - Street 1:3311 CANDELARIA RD NE
Practice Address - Street 2:STE K
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1952
Practice Address - Country:US
Practice Address - Phone:505-300-6390
Practice Address - Fax:866-373-3607
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1714111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor