Provider Demographics
NPI:1255664116
Name:BRIAN E. LARSON, D.C., P.C.
Entity Type:Organization
Organization Name:BRIAN E. LARSON, D.C., P.C.
Other - Org Name:PREMIER CHIROPRACTIC & SPORTS INJURY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-262-0801
Mailing Address - Street 1:189 S BINKLEY ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-8007
Mailing Address - Country:US
Mailing Address - Phone:907-262-0801
Mailing Address - Fax:907-262-0860
Practice Address - Street 1:189 S BINKLEY ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8007
Practice Address - Country:US
Practice Address - Phone:907-262-0801
Practice Address - Fax:907-262-0860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-10
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK396111NR0400X, 111NS0005X
225100000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHG029Medicaid
AKK163193OtherMEDICARE PTAN