Provider Demographics
NPI:1629152319
Name:LARSON, GREG R (DC)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:R
Last Name:LARSON
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 1:13161 BLACK MOUNTAIN RD STE 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2685
Mailing Address - Country:US
Mailing Address - Phone:858-538-8404
Mailing Address - Fax:858-538-0456
Practice Address - Street 1:13161 BLACK MOUNTAIN RD STE 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2685
Practice Address - Country:US
Practice Address - Phone:858-538-8404
Practice Address - Fax:858-538-0456
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 17734111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT18603Medicare UPIN
CADC 17734Medicare ID - Type Unspecified