Provider Demographics
NPI:1922279215
Name:BRANT A. LARSEN D.C., P.A.
Entity Type:Organization
Organization Name:BRANT A. LARSEN D.C., P.A.
Other - Org Name:HEALTH DYNAMICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANT
Authorized Official - Middle Name:A
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-982-1804
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4631111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty