Provider Demographics
NPI:1922213941
Name:LARSEN, BRANT ADAM (BRANT LARSEN DC)
Entity Type:Individual
Prefix:DR
First Name:BRANT
Middle Name:ADAM
Last Name:LARSEN
Suffix:
Gender:M
Credentials:BRANT LARSEN DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LAKE ST N
Mailing Address - Street 2:SUITE 217
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2535
Mailing Address - Country:US
Mailing Address - Phone:651-982-1804
Mailing Address - Fax:
Practice Address - Street 1:25 LAKE ST N
Practice Address - Street 2:SUITE 217
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2535
Practice Address - Country:US
Practice Address - Phone:651-982-1804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4631111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNV04793Medicare UPIN