Provider Demographics
NPI:1689868952
Name:LARSEN, JEREMIAH EMIL (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:EMIL
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:PO BOX 19
Mailing Address - Street 2:
Mailing Address - City:VOLGA
Mailing Address - State:SD
Mailing Address - Zip Code:57071-0019
Mailing Address - Country:US
Mailing Address - Phone:605-627-9919
Mailing Address - Fax:
Practice Address - Street 1:207 KASAN AVE
Practice Address - Street 2:
Practice Address - City:VOLGA
Practice Address - State:SD
Practice Address - Zip Code:57071
Practice Address - Country:US
Practice Address - Phone:605-627-9919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1175111N00000X
SD1144111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor