Provider Demographics
NPI:1518943489
Name:LARSEN, JIM A (DC)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:A
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:JIM
Other - Middle Name:ALLAN
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:709 PETALUMA BLVD N
Mailing Address - Street 2:SUITE B
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2106
Mailing Address - Country:US
Mailing Address - Phone:707-778-8845
Mailing Address - Fax:707-778-6960
Practice Address - Street 1:709 PETALUMA BLVD N
Practice Address - Street 2:SUITE B
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2106
Practice Address - Country:US
Practice Address - Phone:707-778-8845
Practice Address - Fax:707-778-6960
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13342111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT04983Medicare UPIN
CADC0133420Medicare ID - Type Unspecified