Provider Demographics
NPI:1437295136
Name:LARSON, RICHARD THOMAS
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:THOMAS
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:THOMAS
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2198 EASTRIDGE CTR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3403
Mailing Address - Country:US
Mailing Address - Phone:715-833-8050
Mailing Address - Fax:
Practice Address - Street 1:2198 EASTRIDGE CTR
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3403
Practice Address - Country:US
Practice Address - Phone:715-833-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1367111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38830200Medicaid