Provider Demographics
NPI:1245216258
Name:LARSEN, JORN (LPT)
Entity Type:Individual
Prefix:
First Name:JORN
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 N ROXBORO ST
Mailing Address - Street 2:STE 100
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-1888
Mailing Address - Country:US
Mailing Address - Phone:919-479-9001
Mailing Address - Fax:919-479-9003
Practice Address - Street 1:4214 N ROXBORO ST
Practice Address - Street 2:STE 100
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-1888
Practice Address - Country:US
Practice Address - Phone:919-479-9001
Practice Address - Fax:919-479-9003
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2503022CMedicare PIN