Provider Demographics
NPI:1265876056
Name:LARSON, MARK WAYNE (MT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:LARSON
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1505
Mailing Address - Street 2:10093 SUNNY LANE
Mailing Address - City:COLLEGEDALE
Mailing Address - State:TN
Mailing Address - Zip Code:37315-1505
Mailing Address - Country:US
Mailing Address - Phone:423-838-8906
Mailing Address - Fax:
Practice Address - Street 1:10093 SUNNY LN
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-8487
Practice Address - Country:US
Practice Address - Phone:423-838-8906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9061225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist