Provider Demographics
NPI:1790146116
Name:LARSON, JAMES R
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 GRAVEL RD
Mailing Address - Street 2:
Mailing Address - City:SENECA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13148-9773
Mailing Address - Country:US
Mailing Address - Phone:315-651-5472
Mailing Address - Fax:315-282-2300
Practice Address - Street 1:1465 GRAVEL RD
Practice Address - Street 2:
Practice Address - City:SENECA FALLS
Practice Address - State:NY
Practice Address - Zip Code:13148-9773
Practice Address - Country:US
Practice Address - Phone:315-651-5472
Practice Address - Fax:315-282-2300
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-12
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY694 791 581343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)