Provider Demographics
NPI:1619066875
Name:BALSIMO, LARRY STEVEN (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:STEVEN
Last Name:BALSIMO
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 1:4066 WHITE BEAR AVE N
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4305
Mailing Address - Country:US
Mailing Address - Phone:651-407-0402
Mailing Address - Fax:651-407-0413
Practice Address - Street 1:4066 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-4305
Practice Address - Country:US
Practice Address - Phone:651-407-0402
Practice Address - Fax:651-407-0413
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN#2606111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN302L1BAOtherBLUE CROSS BLUE SHIELD