Provider Demographics
NPI:1083836639
Name:LARSON, BRIAN J (CNIM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:LARSON
Suffix:
Gender:M
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1527
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-1527
Mailing Address - Country:US
Mailing Address - Phone:217-342-7256
Mailing Address - Fax:
Practice Address - Street 1:905 W ST ANTHONY AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401
Practice Address - Country:US
Practice Address - Phone:217-342-7256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic