Provider Demographics
NPI:1174019723
Name:LARSON, JUSTIN GRANT (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:GRANT
Last Name:LARSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 POSTAL DR STE 4
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-4798
Mailing Address - Country:US
Mailing Address - Phone:775-727-3838
Mailing Address - Fax:775-727-3781
Practice Address - Street 1:2250 POSTAL DR STE 4
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-4798
Practice Address - Country:US
Practice Address - Phone:775-727-3838
Practice Address - Fax:775-727-3781
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist