Provider Demographics
NPI:1023379773
Name:LARSEN, DYLEN ADAIR (ABOC)
Entity Type:Individual
Prefix:MR
First Name:DYLEN
Middle Name:ADAIR
Last Name:LARSEN
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:521 SOUTH STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008
Mailing Address - Country:US
Mailing Address - Phone:815-520-1303
Mailing Address - Fax:815-975-9327
Practice Address - Street 1:521 SOUTH STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008
Practice Address - Country:US
Practice Address - Phone:815-520-1303
Practice Address - Fax:815-975-9327
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician