Provider Demographics
NPI:1821314824
Name:LARSEN, GERALD BURKELY (DC)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:BURKELY
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:BURKE
Other - Middle Name:
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 9641
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84409-0641
Mailing Address - Country:US
Mailing Address - Phone:801-479-3200
Mailing Address - Fax:
Practice Address - Street 1:5319 ADAMS AVE PKWY
Practice Address - Street 2:STE D
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4773
Practice Address - Country:US
Practice Address - Phone:801-479-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7564602-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor