Provider Demographics
NPI:1518291772
Name:MICHAEL CRAIG LARSEN AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:MICHAEL CRAIG LARSEN AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-444-1411
Mailing Address - Street 1:675 S 600 E
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4278
Mailing Address - Country:US
Mailing Address - Phone:801-444-1411
Mailing Address - Fax:
Practice Address - Street 1:461 SKYMASTER CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1909
Practice Address - Country:US
Practice Address - Phone:707-437-4095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11165152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty