Provider Demographics
NPI:1376701367
Name:LARSON, VICKI J
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:J
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 E POWERLINE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-4920
Mailing Address - Country:US
Mailing Address - Phone:208-353-0329
Mailing Address - Fax:
Practice Address - Street 1:2914 E POWERLINE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-4920
Practice Address - Country:US
Practice Address - Phone:208-353-0329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806519600Medicaid