Provider Demographics
NPI:1891273108
Name:LARSON, DANIEL W (LDN)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:W
Last Name:LARSON
Suffix:
Gender:M
Credentials:LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 W JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5606
Mailing Address - Country:US
Mailing Address - Phone:312-648-4666
Mailing Address - Fax:312-648-0155
Practice Address - Street 1:444 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-6923
Practice Address - Country:US
Practice Address - Phone:312-627-0444
Practice Address - Fax:312-648-0155
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164007258133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered