Provider Demographics
NPI:1184953739
Name:LARSEN, MATTHEW WAYNE (RDN, CDE)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:WAYNE
Last Name:LARSEN
Suffix:
Gender:M
Credentials:RDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 SUNNYVIEW LN STE 103
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3128
Mailing Address - Country:US
Mailing Address - Phone:406-257-3872
Mailing Address - Fax:406-758-7077
Practice Address - Street 1:210 SUNNYVIEW LN STE 103
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901
Practice Address - Country:US
Practice Address - Phone:406-257-3872
Practice Address - Fax:406-758-7077
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
MT59321133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered