Provider Demographics
NPI:1508953464
Name:LARSON-BRUNNER, KELLY (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:LARSON-BRUNNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 LARRABEE RD
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-4744
Mailing Address - Country:US
Mailing Address - Phone:207-854-2001
Mailing Address - Fax:207-854-2004
Practice Address - Street 1:89 LARRABEE RD
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4744
Practice Address - Country:US
Practice Address - Phone:207-854-2001
Practice Address - Fax:207-854-2004
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1284111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MELA MM9377Medicare ID - Type UnspecifiedMEDICARE LEGACY NUMBER