Provider Demographics
NPI:1346312147
Name:CHRISTOPHER R. LARSON, D.C., P.A.
Entity Type:Organization
Organization Name:CHRISTOPHER R. LARSON, D.C., P.A.
Other - Org Name:BACK IN SHAPE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:R
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-595-9096
Mailing Address - Street 1:20843 GRANADA AVENUE CT N
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-8151
Mailing Address - Country:US
Mailing Address - Phone:651-270-8427
Mailing Address - Fax:
Practice Address - Street 1:669 WINNETKA AVE N
Practice Address - Street 2:SUITE 202
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4574
Practice Address - Country:US
Practice Address - Phone:763-595-9096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3816111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU77666Medicare UPIN