Provider Demographics
NPI:1790743060
Name:LARSEN, KIMBERLY R (MS DC RD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:R
Last Name:LARSEN
Suffix:
Gender:F
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 1:7130 W CHANDLER BLVD
Mailing Address - Street 2:STE 19
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-3241
Mailing Address - Country:US
Mailing Address - Phone:480-753-5999
Mailing Address - Fax:480-753-6999
Practice Address - Street 1:7130 W CHANDLER BLVD
Practice Address - Street 2:STE 19
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-3241
Practice Address - Country:US
Practice Address - Phone:480-753-5999
Practice Address - Fax:480-753-6999
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7109111N00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ7764321OtherAETNA
AZAZ0156830OtherBC/BS
AZ7764321OtherAETNA
AZU82609Medicare UPIN