Provider Demographics
NPI:1003971458
Name:LARSEN, M. CHAD (DC)
Entity Type:Individual
Prefix:
First Name:M.
Middle Name:CHAD
Last Name:LARSEN
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 1:1477 US HIGHWAY 19 S
Mailing Address - Street 2:P O BOX 734
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-4868
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
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR003115111N00000X
WACH00002535111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor