Provider Demographics
NPI:1205954195
Name:M. CHAD LARSEN DC PC
Entity type:Organization
Organization Name:M. CHAD LARSEN DC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:M.
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:229-436-1191
Mailing Address - Street 1:PO BOX 734
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-0734
Mailing Address - Country:US
Mailing Address - Phone:229-436-1191
Mailing Address - Fax:229-436-1140
Practice Address - Street 1:1477 US HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-4868
Practice Address - Country:US
Practice Address - Phone:229-436-1191
Practice Address - Fax:229-436-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty