Provider Demographics
NPI:1013931021
Name:LARSON, KEITH (PT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 50469
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0469
Mailing Address - Country:US
Mailing Address - Phone:530-778-0200
Mailing Address - Fax:
Practice Address - Street 1:10450 PARK MEADOWS DR.
Practice Address - Street 2:SUITE 103
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124
Practice Address - Country:US
Practice Address - Phone:303-754-5222
Practice Address - Fax:303-754-5201
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6389225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC809786Medicare PIN