Provider Demographics
NPI:1659644409
Name:LARSON, KEVIN T (DC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
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 1:1250 TECH DR STE 460
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-6245
Mailing Address - Country:US
Mailing Address - Phone:770-638-7246
Mailing Address - Fax:770-806-0991
Practice Address - Street 1:1250 TECH DR STE 460
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-6245
Practice Address - Country:US
Practice Address - Phone:770-638-7246
Practice Address - Fax:770-806-0991
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005852111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor