Provider Demographics
NPI:1619053931
Name:LARSEN, MICHAEL L (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 E LOSEY ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-3874
Mailing Address - Country:US
Mailing Address - Phone:309-342-2777
Mailing Address - Fax:309-342-6702
Practice Address - Street 1:1052 E LOSEY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-3874
Practice Address - Country:US
Practice Address - Phone:309-342-2777
Practice Address - Fax:309-342-6702
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006092111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004882015OtherBLUE CROSS BLUE SHIELD
IL038006092Medicaid
350015512OtherRAILROAD MEDICARE
350015512OtherRAILROAD MEDICARE
T87442Medicare UPIN