Provider Demographics
NPI:1639127442
Name:LARSEN, NELS V (MS DC RD)
Entity Type:Individual
Prefix:DR
First Name:NELS
Middle Name:V
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MS DC RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-0091
Mailing Address - Country:US
Mailing Address - Phone:602-237-2555
Mailing Address - Fax:480-275-3774
Practice Address - Street 1:5099 W DOBBINS RD
Practice Address - Street 2:STE B
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-9733
Practice Address - Country:US
Practice Address - Phone:602-237-2555
Practice Address - Fax:480-275-3774
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7110111N00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ7139212OtherAETNA
AZAZ0156940OtherBC/BS
AZ7139212OtherAETNA
AZ105595Medicare ID - Type Unspecified