Provider Demographics
NPI:1124413703
Name:LARSEN, KIRK
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HARTFORD TPKE
Mailing Address - Street 2:COHENS FASHION OPTICAL
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4238
Mailing Address - Country:US
Mailing Address - Phone:860-444-7360
Mailing Address - Fax:860-444-1800
Practice Address - Street 1:850 HARTFORD TPKE
Practice Address - Street 2:COHENS FASHION OPTICAL
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4238
Practice Address - Country:US
Practice Address - Phone:860-444-7360
Practice Address - Fax:860-444-1800
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001095156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician